403.7E3 - Religious Accommodation Request Form

 

Date:

 

Employee Name:

 

Email Address:

 

Position/Job Title:

 

Employee Telephone Number:

 

Employment Location:

 

 

  1. Please identify the policy requirement or practice that conflicts with your sincerely held religious observance, practice or belief:

 

  1. Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflict with the policy or practice you have identified above:

 

(3) What are you requesting an accommodation from?

 

Item

Yes/No

Vaccination for COVID-19

 

Testing for COVID-19

 

Use of Face Coverings

 

 

 

 

 

 

___________________________________  ________________________________

Employee Signature  Date

Office Use

This request has been:

______________________________  ________________________________

Approved  Denied

_________________________________________  ______________________________

Administrator  Date