Cornell University Request For Religious Accommodation Form printable pdf download

PLEASE SUBMIT THIS COMPLETED TWO-PAGE FORM

TO YOUR IMMEDIATE SUPERVISOR

Cornell University

Request for Religious Accommodation

To be completed by Faculty, Staff or Student-Employee

consider the approval

Contents of this request will be shared only as necessary to

and/or implementation of an appropriate accommodation.

Employee Information

Date: ________________________________________

Name of Employee Requesting Accommodation: ______________________________________________________________________

Employee’s Department/College/Unit: _______________________________________________________________________________

Employee’s Title: ____________________________________________ Work Phone #________________________________________

Status: (Check one) Faculty ___ Staff ___ Student-Employee ___

Campus Mailing Address: _______________________________________________________________________________________

E-Mail Address ___________________________ How do you prefer we contact you? E-mail _____ Work Phone ____ Mail ____

Are you a member of a collective bargaining unit? Yes _____No _____

If “Yes” please provide us with the name of the collective bargaining unit: ________________________________________________

Name of Immediate Supervisor: ____________________________________________________________________________________

Position/Title: ________________________________________ Work Phone # _________________ E-mail _______________________

Name of Department Head: _______________________________________________________________________________________

Position/Title: ________________________________________ Work Phone # _________________ E-mail _______________________

Name of Human Resource Representative: __________________________________________________________________________

Position/Title: ________________________________________ Work Phone # _________________ E-mail _______________________

Request for Religious Workplace Accommodation

A reasonable religious workplace accommodation is a change in the work environment or in the way tasks or responsibilities are

customarily done that enables an employee to participate in his/her religious practice or belief without undue hardship on the conduct of

Cornell University’s business or operation, and that complies with the university’s commitment to diversity and inclusiveness. See

University Policy 6.13.8 Religious Accommodation for more details. To consider your request for a religious workplace accommodation,

please provide the following information:

What specific workplace accommodation do you request? (For example, time to pray, leave for religious observance, religious attire, etc.)

____________________________________________________________________________________________________________

Cornell University Request For Religious Accommodation Form