Religious Accommodation Request Form Template

Religious Accommodation Request Form Template
Employee Name
First NameLast Name
Personnel Number
Describe the religious belief, practice, or observance that is the basis of a religious accommodation request
Does your religious belief, practice, or observance lead you to all medical treatment?
Does your religious belief, practice, or observance lead you to all vaccinations?
Does your religious belief, practice, or observance lead you to only the COVID-19 vaccination?
Briefly explain how your sincerely held religious belief, practice, or observance conflicts with the COVID-19 vaccination requirement.
Briefly describe the accommodation you are requesting.
If the request for accommodation is temporary, please identify the anticipated date the accommodation is no longer needed:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that I have read and understood the information provided in this request, and that I have truthfully completed it based on my knowledge, information, and belief.
Employee Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: