Human Resources
Religious Accommodation Request
Part 1 - To be completed by Employee
Name: _________________________________ Department: ____________________________
Immediate Supervisor: ____________________________________________________________
Date of Request: ______________
Reason for Request (Job Change, Work Schedule, Dress/Appearance Code, Other):
Length of Time: _________________________________________________________________
Suggested religious accommodation:
I have read and understand the Board of Regent’s policy on religious accommodation. My religious
beliefs and practices, which result in this request for a religious accommodation, are sincerely held. I
understand that the accommodation requested above may not be granted but that the university will
attempt to provide a reasonable religious accommodation that does not create an undue hardship on
the employers business.
Employee Signature: ____________________________________ Date: ____________
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Human Resources
Part 2 - To be completed by immediate supervisor (and additional managers, if applicable)
Employees suggested accommodation:
Evaluation of Impact (if any):
Accepted: _____ Not accepted: _____
Alternative accommodations (list in order of preference):
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
Discussed with Employee on: _________________________________________
Accommodation agreed upon: _________________________________________
If no agreement on an accommodation, explanation:
Supervisor/ Chair Signature: _____________________________________ Date: _________
Director/ Dean Signature: _____________________________________ Date: _________
HR Director Signature: _________________________________________ Date: __________
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signature
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signature
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signature
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