Religious Accommodation Request Form

Religious Accommodation Request Form
Name:

First Name Last Name
E-mail:*
Phone Number:

Area Code Phone Number
Student or Employee:
Department/Program:
Employee Title and Position:
Supervisor's name and e-mail:
Name and e-mail of faculty member who would oversee implementation of accommodation:
Identify the policy, practice, schedule or patient care for which you are seeking a religious accommodation:
Explain how such policy, practice, schedule or patient care conflicts with your religious beliefs:
Describe the accommodation or modification that you are requesting:
List any other accommodations that would eliminate the conflict:
Duration:
Specific date(s):
Ongoing: Describe the schedule (i.e. daily 8am-9am, every other Monday, monthly, etc):