Office Use Only
Approved by:
Date:
STUDENT REQUEST FOR ABSENCE
FOR REASONS OF FAITH OR CONSCIENCE
Today’s Date: ___________________ Quarter:_________________ SID #:____________________
Student Name: ___________________ Email:___________________ Phone:___________________
Columbia Basin College welcomes diversity of experiences, perspectives, and beliefs, which enhances the teaching and
learning environment. Consistent with these values and pursuant to RCW 28B.10.039 as amended, and S.S. Bill 5166, the
College reasonably accommodates student absences for reasons of faith or conscience or for organized activities conducted
under the auspices of a religious denomination, church, or religious organization.
Instructions:
1. Submit this completed Student Request for Absence for Reasons of Faith or Conscience form to the Office of
Instruction via email at instruction@columbiabasin.edu, w
ith the subject line, “Request for Absence for Reasons of
Faith or Conscience”, or by delivery to the Office of Instruction, A-Building, Pasco Campus.
2. Upon receiving approval from the Office of Instruction, present this form to each of your instructors whose courses or
assignments are related to the absence for their signature as acknowledgment of the dates of your absence. Return
this signed form to the Assistant Dean for Instruction, A-Building, Pasco Campus.
3. It is your responsibility to work with each of your instructors to complete any required assignments or activities
which are due during your absence.
LIST ALL COURSES RELATED TO THIS REQUEST
Brief explanation of reason for requested
absence
Student
Signature: __________________________________________________ Date _________________________
FACULTY ACKNOWLDEGEMENT FOR EACH COURSE RELATED TO THIS REQUEST
4. A st
udent whose request for absence is denied may appeal the determination to the Vice President for Instruction.
The appeal must be in writing and must be delivered to the Office of Instruction within three (3) calendar days after
the student receives notice of the denial.
