403.7E3 Religious Accommodation Request form - SUSPENDED 1-19-2022

 

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:

    

(2) 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

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Office Use

This request has been:

______________________________  ________________________________

Approved                                                               Denied

         ______________________________  ______________________________

Administrator                                                          Date