Accommodation Request Form For Closely Held Personal and/or Religious Beliefs
SECTION 1 - EMPLOYEE PROFILE: To Be Completed By the Employee
Employee Name	Employee ID	Office Telephone Number	Alternate Telephone Number
Title	Department	HR Generalist
Immediate Supervisor	Supervisor’s Title	Supervisor’s Telephone Number
SECTION 2 – REQUEST DETAILS: To Be Completed By Employee
Please specify the closely held personal and/or religious belief, practice or observance obligation that is the basis for your request for accommodation(s).
Please specify the work requirement that conflicts with the closely held personal and/or religious belief, practice or observance obligation described above and explain the nature, duration and frequency of the conflict.
Please describe the specific accommodation(s) that you are requesting at this time.
SECTION 3 – EMPLOYEE ACKNOWLEDGEMENT
I certify, to the best of my knowledge and belief, that the statements made by me on this form are true, complete, and correct. My closely held personal and/or religious beliefs and practices, which result in this request for a workplace accommodation, are sincerely held. I agree to maintain confidentiality regarding this matter and I understand that the department will discuss this matter with only those individuals with a business need to know. I understand that the accommodation(s) requested above may not be granted but the department will attempt to provide a reasonable accommodation that does not create an undue hardship.
Employee Signature:	Date
SECTION 4 – IMMEDIATE SUPERVISOR ACKNOWLEDGEMENT OF RECEIPT
Attention Immediate Supervisor: You must contact a representative from Integrated Ethics immediately upon receipt of this request.
Immediate Supervisor Signature	Date Request Received	Date Integrated Ethics Notified