Cornell University Request For Religious Accommodation Form (Page 2 of 2) in pdf

PLEASE SUBMIT THIS COMPLETED TWO-PAGE FORM

TO YOUR IMMEDIATE SUPERVISOR

Identify your religious practice or belief and state how this accommodation enables you to participate in your religious practice or belief

without impacting your ability to meet the required functions of your position.

_____________________________________________________________________________________________________________

State date[s]/frequency of requested accommodation (e.g., daily or weekly religious requirements) within academic (fiscal) year.

______________________________________________________________________________________________________________

If you have requested this religious accommodation before, please state approximately when the request was made, the name of the

individual who responded to the request, and the outcome of the request.

_____________________________________________________________________________________________________________

(IF NECESSARY, PLEASE USE ADDITIONAL SHEETS FOR ANY OF THE INFORMATION REQUESTED ABOVE)

_____________________________________________________________________________________

Religion Tenet(s) Documentation

If requested, can you obtain documentation or other authority to support the need for an accommodation based on your religious practice

or belief? Yes _____No _____

Please Note: In some cases, Cornell University will need to obtain documentation or other authority regarding your religious practice or

belief. We may need to discuss the nature of your religious belief(s), practice(s) and accommodation with your religion’s spiritual leader

(if applicable) or religious scholars to address your request for an accommodation.

I verify that the above information is complete and accurate to the best of my knowledge and I understand that any intentional

misrepresentation contained in this request may result in disciplinary action.

Signature:______________________________________________________________________ Date:________________________

Summary of Next Steps

This request will be reviewed with you and acknowledged by your supervisor below.

Your supervisor will then submit your request to the appropriate human resource representative for consideration.

You will be notified of the outcome of the determination and/or proposed accommodation.

Please consult Policy 6.13.8

for information about how to resolve any disagreements with the determination or proposed accommodation, including contacting

the office of Workforce Policy and Labor Relations or the University Ombudsman for assistance.

_______________________________________________________________________________________________________________

For supervisor’s use only:

Date received:_____________

Received by: ________________________________

Form is: Complete / Incomplete

(Supervisor’s signature)

(Circle one)

Cornell University Request For Religious Accommodation Form Page 2