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Religious Reasonable Accommodation Form EMPLOYEES AND STUDENTS Employees and students complete this form to request a reasonable religious accommodation PLEASE PRINT OR TYPE ATTACH EXTRA SHEETS IF NECESSARY 1. Describe the current impact and/or limitations imposed by your desire for reasonable religious a. Day s date s and time s of religious holiday e.g. sundown Monday September 29 through sundown Tuesday September 30 Rev. 06/07 Religious Reasonable Accommodation Form Employees and Students Page 1 of 2 Describe work shift/schedule affected b. I authorize my religious affiliate to discuss my need for reasonable accommodation with OHSU. Signature of person requesting reasonable religious accommodation Date Once completed mail fax or return this form in person to Affirmative Action Equal Opportunity Department Oregon Health Science University 2525 SW Third Avenue Mail Code MP240 Portland OR 97239 Phone 503 494-5148 FAX 503 494-8810 A separate form must be submitted for each work shift/schedule affected.. Name Street Address City State Home Phone Zip Code Work Phone E-mail Address Employees Students Hire Date Admission Date Job Title School Department Immediate Manager 2. Name of religion 3. Please outline the specific religious practices and/or requirements that you feel need reasonable 4. Clothing and/or attire. Please explain* Other. Please explain* 6. Is there any other information that would help us evaluate your request 7. A recognized professional i*e* religious affiliate who is familiar with your needs and can substantiate your request may need to be contacted* Please provide the following information regarding the religious affiliate Name of Professional Title Represented Organization Telephone AUTHORIZATION I hereby give authorization to Oregon Health Science University OHSU to discuss my circumstances with the recognized professional religious affiliate named above. Name Street Address City State Home Phone Zip Code Work Phone E-mail Address Employees Students Hire Date Admission Date Job Title School Department Immediate Manager 2. Name of religion 3. Please outline the specific religious practices and/or requirements that you feel need reasonable 4. Clothing and/or attire. Please explain* Other. Please explain* 6. Is there any other information that would help us evaluate your request 7. A recognized professional i*e* religious affiliate who is familiar with your needs and can substantiate your request may need to be contacted* Please provide the following information regarding the religious affiliate Name of Professional Title Represented Organization Telephone AUTHORIZATION I hereby give authorization to Oregon Health Science University OHSU to discuss my circumstances with the recognized professional religious affiliate named above.

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