Religious Accommodation Request

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Name

Pronouns (i.e. she, they, he, ze, per, etc.)

Date of Request

School

Department/Work Unit (please do not abbreviate)

If you are a student, what year are you in?

Telephone or Cell Phone Number

Email Address (HIDDEN)

Email Address

Hopkins Affiliation

Are you requesting an influenza vaccine exemption?

Are you requesting an exemption from JHU's required immunizations (measles, mumps, rubella, or meningitis)?

Reason for Request (please explain how your need for a religious accommodation is connected to your sincerely held religious beliefs): *

Before approving religious accommodation requests, we are required to engage in an interactive process where you share the reason for your request. In this way, please explain in as much detail as possible how your request is connected to your sincerely held religious beliefs. Should we require additional information, we will contact you via e-mail and/or phone.

Suggested reasonable accommodation to meet your requirements or limitations:

Days Affected

Shifts (if applicable)

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

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

Verification and Accuracy *

Verification and Accuracy 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.* I also understand that my request for an accommodation may not be granted if it is not reasonable or if it creates an undue hardship on my employer/academic environment.*

Signature

Date Date / MM / DD YYYY

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