Equal Opportunity, Affirmative Action, and Disability Services Department
Religious Reasonable Accommodation Request Form
In accordance with federal and state laws and Vanderbilt University policies,
Vanderbilt University prohibits discrimination on the basis of religion.
Vanderbilt provides reasonable accommodation for a person’s sincerely held
religious/personal beliefs or practices unless the accommodation would
impose an undue hardship on Vanderbilt.
A reasonable religious
accommodation is any adjustment to the work and/or academic environment
that will allow the individual to practice his/her religion.
In general, an applicant for admission or student should inform the requisite
department or EAD about a request for reasonable accommodation. An
employee should inform his/her supervisor that he/she needs a religious
accommodation. An employee should notify management as soon as he/she
becomes aware of a need or potential need for accommodation. Vanderbilt
is not required to provide an accommodation if is not aware of the
individual’s need and desire for accommodation.
Reasonable
accommodations are determined, identified, and implemented using a
collaborative process. Contents of this request are confidential and will only
be shared with appropriate personnel to consider the implementation of a
reasonable accommodation. This form will not be placed in employment
records. The information may be released to external agencies.
Equal Opportunity, Affirmative Action, and Disability Services
Department
Baker Building, Suite 808
110 21st Avenue South
Nashville, TN 37203
615.322.4705 (V/TDD)
2/18/16
Fax: 615.343.4969
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Equal Opportunity, Affirmative Action, and Disability Services Department
Religious Reasonable Accommodation Request Form
Part I
(Part I is to be filled out by the person requesting a religious reasonable
accommodation and submitted to the EAD Department.)
S T UDE NTS or APPLI CANTS FO R ADMIS SI ON
Name:
Department/School/Program:
Phone Number:
E-mail address:
E MPLO YEE S ONL Y
Name:
Title/Position:
Department:
Phone Number:
E-mail address:
Immediate Supervisor:
Supervisor’s phone number:
2/18/16
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Equal Opportunity, Affirmative Action, and Disability Services Department
Religious Reasonable Accommodation Request Form
Please specify the religious/personal belief or practice you have for which you are
requesting accommodation.
What policy, practice, or schedule do you desire to have modified? For employees,
what aspect of the employee's job should be modified?
What reasonable accommodations are you requesting at this time? What are some
accommodation options?
2/18/16
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Equal Opportunity, Affirmative Action, and Disability Services Department
Religious Reasonable Accommodation Request Form
Please attach additional documentation that you think would be helpful in
evaluating your request (if necessary).
Signature
Date
Part II
(Part II is to be filled out by the EAD).
Did documentation come with the request?
Yes
No
Is more documentation necessary?
Yes
No
Reasonable
accommodation:
Approved
Denied
Denied due to Undue
Hardship
Nature of accommodation provided:
Date reasonable accommodation approved or denied:
Authorized person approving or denying the accommodation:
Date reasonable accommodation provided (if different from date approved):
Costs associated with the
reasonable accommodation:
Individuals consulted in evaluating the reasonable accommodation (HR, Legal or External):
Additional Comments:
EAD Representative
2/18/16
Date
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