RELIGIOUS ACCOMMODATION REQUEST FORM
Applicant's or Employee's Name: Date
of
Request:
Email Address: Telephone Number:
Employee's Position: Duty Location:
1) Please identify the EEOC requirement, policy, or practice that conflicts with your
sincerely held religious observance, practice, or belief (hereinafter "religious
beliefs").
2) Please describe the nature
of
your sincerely held religious beliefs or religious
practice or observance that conflict with the EEOC requirement, policy, or practice
identified above.
3) What is the accommodation or modification that you are requesting?
4) List any alternative accommodations that also would eliminate the conflict between
the EEOC requirement, policy, or practice and your sincerely held religious beliefs.
Requester Signature: Date:
Accommodation Decision
Accommodations:
□
approved as requested
□
approved but different from the original request
□
denied
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Identify the accommodation provided.
If the approved accommodation is different from the one originally requested, explain
the basis for denying the original request.
If
an alternative accommodation was offered, indicate whether it was:
□
accepted
□
rejected
If it was rejected, state the basis for rejection.
If the accommodation is denied and no alternative accommodation was proposed,
explain the basis for denying the request without an alternative accommodation.
An individual who disagrees with the resolution
of
the request may ask the Chief
Human Capital Officer to reconsider that decision within 10 business days
of
receiving
this completed form with the Deciding Official's decision. Note that requesting
reconsideration does not extend the time limits for initiating administrative, statutory, or
collective bargaining claims.
If
an individual is dissatisfied with the resolution and wishes to pursue administrative,
statutory, or collective bargaining rights, they must take the following steps:
• For an EEO complaint pursuant to 29 C.F.R. part 1614, contact
an
EEO
counselor
in
the Office
of
Equal Opportunity within 45 days from the date
of
receipt
of
this form or a verbal response, whichever comes first.
• For a collective bargaining claim, file a written grievance
in
accordance with the
provisions
of
the collective bargaining agreement.
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• For adverse actions over which the Merit Systems Protection Board has
jurisdiction, initiate an appeal to the MSPB within 30 days
of
an appealable
adverse action as defined
in
5 C.F.R. § 1201.3
Religious Accommodation Case Number:
Deciding Official Name:
Deciding Official Signature:
Date:
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