Religious Accommodation Request Form

A workplace form for employees to request a religious accommodation related to schedule, attire, grooming, observance, or other religious practices.

Employee Information

• Full Name
• Work Email
• Employee ID
  Optional if your organization uses employee IDs for routing.
• Department
• Manager Name

Accommodation Request Details

• Type of Accommodation Requested
• Brief Description of Your Request
  Describe the accommodation you are requesting and the workplace policy or practice involved.
• How Does This Affect Your Work Schedule or Duties?
  Explain the impact only as needed to evaluate the request.
• Requested Start Date
• Requested End Date
  Leave blank if this is an ongoing request.

Religious Practice or Observance Details

• Describe the Religious Practice or Observance
  Provide enough detail for HR to understand the request. Do not include sensitive information unless it is necessary.
• How Often Is the Accommodation Needed?
• Specific Days or Times
  Use this field for recurring schedules, observance periods, or time windows.
• Policy, Dress Code, or Work Requirement Involved
  Identify the rule or requirement that conflicts with your religious practice, if known.

Requested Accommodation and Alternatives

• Preferred Accommodation
• Alternative Options That Would Also Work
  List any alternatives you would consider if the preferred option is not feasible.
• Any Known Operational Impact
  Describe any scheduling, coverage, or operational concerns you are aware of.

Supporting Information

• Supporting Documents
  Optional documents that help explain the request, such as a schedule conflict notice or policy reference.
• Additional Comments

Acknowledgment, Consent, and Confidentiality

• I confirm that the information provided is accurate to the best of my knowledge.
• I consent to HR reviewing this information for the purpose of evaluating my accommodation request.
• Confidentiality Notice
  Your request may include PII and information about sincerely held religious beliefs. It will be handled confidentially and shared only on a need-to-know basis for processing and implementing the accommodation.
• Anonymous Submission Preference
  Choose whether you want to identify yourself or submit without your name. Anonymous submission may limit HR's ability to evaluate or implement the request.