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Uic Employee Request For Reasonable Accommodation Based On Religious Reason - Office For Access And Equity

UIC Employee Request for Reasonable

Accommodation Based on Religious Reason

This form is to be used when an individual is seeking a religious accommodation because his or her sincerely held religious

belief(s) or practice(s) conflict with the work environment.

SECTION 1: EMPLOYEE’S INFORMATION AND REQUEST (

To Be Completed By Employee)

First Name

Last Name

Phone Number

Job Title/Classification

Street Address

City

State

Zip Code

College/Department/Unit

Status (AP, Extra Help, Faculty, Support Staff)

Supervisor’s First Name

Supervisor’s Last Name

Supervisor’s Phone Number

Supervisor’s Email

Identify Requested Accommodation

Identify duration and length of requested accommodation (e.g. temporary or permanent; amount of time)

Certification: My religious beliefs and practices, which result in this request for a religious accommodation, are sincerely

held. I understand that my request for an accommodation may not be granted if it is unreasonable and/or if it creates an

undue hardship on my employer. I understand I may be asked to provide verification.

Employee Signature

Date

Revised November 2016

| 312.996.8670

Uic Employee Request For Reasonable Accommodation Based On Religious Reason - Office For Access And Equity