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Date: |
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Employee Name: |
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Email Address: |
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Position/Job Title: |
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Employee Telephone Number: |
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Employment Location: |
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(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?
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Yes/No |
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Vaccination for COVID-19 |
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Testing for COVID-19 |
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Use of Face Coverings |
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Employee Signature Date
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Office Use
This request has been:
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Approved Denied
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Administrator Date
