Employee Religious Accommodation Request Form
Use this form to request a workplace adjustment when a sincerely held religious belief, practice, or observance conflicts with a work requirement. Submit the completed form to Human Resources. Employees may contact Human Resources by email to provide initial notice of a request, ask questions, or address an immediate need; however, this form must be completed and submitted for the College’s records.
Full Name
*
First Name
Last Name
Work Email Address
*
example@ric.edu
Phone
-
Area Code
Phone Number
Job title
Department or school
Employee group
*
Faculty
Staff
Other
If Other, please specify
Accommodation Request Details
Describe the religious belief, practice, or observance involved and how it conflicts with a work requirement.
*
Describe the accommodation you are requesting.
*
Date accommodation is needed
*
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Month
-
Day
Year
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Expected duration or frequency.
Optional: Describe any alternative accommodation you believe could also resolve the conflict.
Additional information
You do not need to submit a clergy letter or other supporting documentation with this form. Human Resources may ask for limited additional information only when it is reasonably necessary to understand or evaluate the request.
Signature
*
By signing, I confirm that the information provided is accurate to the best of my knowledge and understand that Human Resources may discuss relevant operational information with my supervisor or other College officials who need the information to evaluate or implement the request.
Date
*
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Month
-
Day
Year
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Submit Request
Submit Request
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