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Run: Religious Accommodation Request

A Religious Accommodation Request form for documenting an employee’s request, the religious basis, work impact, and proposed alternatives. Use it to create a...

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Employee Information

Employee Name (required)

Employee ID

Optional if your organization uses employee IDs for routing.

Work Email (required)

Department (required)

Manager Name

Request Details

Type of Accommodation Requested (required)

Requested Start Date (required)

Requested End Date

Leave blank if the request is ongoing or indefinite.

How soon is this needed? (required)

Describe the accommodation you are requesting (required)

Briefly explain what change you are requesting and why it is needed.

Religious Practice or Observance Details

What religious belief, practice, or observance is connected to this request? (required)

You may describe the belief or practice in your own words. Do not include more detail than needed.

Is this request based on a sincerely held religious belief, practice, or observance? (required)

How often is the accommodation needed?

How does the current policy or schedule affect your ability to work?

Describe the impact only as it relates to the accommodation request.

Work Impact and Alternatives

What accommodation do you think would work best?

Are there other accommodations that would also meet your needs?

Would the requested accommodation affect any essential job duties?

If yes, which duties may be affected?

Supporting Information

Upload any supporting documents

Optional. Examples: schedule constraints, policy references, or other supporting materials.

Additional comments

Acknowledgment and Consent

I consent to HR reviewing this request and contacting me about it. (required)

Yes No N/A

I understand that my request will be handled confidentially to the extent possible, but may be shared with those who need to know to evaluate or implement an accommodation. (required)

Yes No N/A

I understand that requesting a religious accommodation will not result in retaliation. (required)

Yes No N/A

Signature (required)

Submission Date (required)

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Email (required)

Your name (optional)

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