Religious Accommodation Request Form

Title VII of the Civil Rights Act of 1964 requires employers to provide accommodations to employees for sincerely held religious beliefs that can be accommodated without an undue hardship to the employer.¹

Employer-employee cooperation and flexibility are key to evaluating reasonable accommodations.

As we begin the interactive process to review your request for an accommodation, please provide the information requested below.

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¹ The EEOC has provided guidance that undue hardship is evaluated as being substantial to the overall context of an employer’s business; for example, if it would cause more than de minimis cost on the overall operation and/or diminish efficiency in other jobs or impair workplace safety.

Name

Work Location/Department

Email Address

Please identify the religious belief, practice or observance that is the reason you are seeking a workplace accommodation

Please describe the specific accommodation you are requesting

Please identify the time period you are seeking the accommodation

After the information is received, the Executive Director of Human Resources will follow up with you directly and provide you the opportunity to further dialogue about your request and seek any additional clarification.

Please know that the information will be treated confidentially and carefully considered. Also, if the preferred accommodation cannot be provided, alternative accommodations may also be considered.

By submitting this form, you affirm the request is based on a sincerely held religious belief.