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

UNC CHARLOTTE

REQUEST FOR ACCOMMODATION FOR RELIGIOUS OBSERVANCE

FOR INSTRUCTOR USE ONLY

Name of student: __________________________________________________ Date of submission: _________________________

Select one of the following two options:

OPTION #1: Accommodation Approval

What specific accommodation will be provided?

_____________________________________________________________________________________________________________

State date[s] or duration for the accommodation:

_____________________________________________________________________________________________________________

Instructor Signature: ____________________________________________________ Date: _________________________________

___________________________________________ _______________________________

_______________________________

___________________________________________

OPTION #2: Accommodation Denial

Ultimate outcome and reason for denial, e.g., requested accommodation required significant expense or difficulty, including a

significant interference with the essential functions of the course/program of study (specify):

_____________________________________________________________________________________________________________

Note: If there is no consensus on a reasonable accommodation, either party or both should seek the advice of the department chair.

Instructor Signature: ____________________________________________________ Date: _________________________________

RETURN COMPLETED FORM TO THE STUDENT W/IN FIVE BUSINESS DAYS OF SUBMISSION.

SUBMIT A COPY TO YOUR DEPARTMENTAL OFFICE.

KEEP A COPY IN YOUR FILES.

Request For Religious Accommodation Form Page 2