3 Reasonable Accommodation Form: Religious

REQUEST FOR A RELIGIOUS ACCOMMODATION
To request a religious accommodation, please fill out this form. If more space is needed, please
attach documents as necessary. AmeriCorps may ask for other information as needed to
determine if you are legally entitled to a religious accommodation.
By signing this form, you declare that the information you provide is true and correct to the best
of your knowledge and ability. Any intentional misrepresentation to the Federal Government may
result in legal consequences, including termination or removal from Federal Service.
Privacy Act Statement
Authority:
Reasonable accommodation without undue hardship as required by section 701(j) of Title VII of
the Civil Rights Act of 1964, 42 U.S.C. § 2000e; 29 CFR § 1605.2; 5 U.S.C. chapters 11 and 79.
Purpose:
AmeriCorps is requesting this information to track and report the processing of religious
accommodation requests to comply with applicable law and regulations, and to preserve and
maintain the confidentiality of religious information consistent with the referenced
authorities. Failure to fully complete the form or refusal to provide the requested
documentation may lead to a breakdown in the reasonable accommodation process and your
request may be denied.
Routine Uses:
The information requested on this form is intended to be used primarily for internal purposes.
However, in certain circumstances it may be necessary to disclose this information externally.
Examples include: to disclose information to: a Federal, state, or local agency to the extent
necessary to comply with laws governing reporting of communicable disease or other laws
concerning health and safety in the work environment; to adjudicative bodies (e.g., the Merit
System Protection Board), arbitrators, and hearing examiners to the extent necessary to carry out
their authorized duties regarding Federal employment; to contractors, grantees, or volunteers as
necessary to perform their duties for the Federal Government; to other agencies, courts, and
persons as necessary and relevant in the course of litigation, and as necessary and in accordance
with requirements for law enforcement; or to a person authorized to act on your behalf. A
complete list of the routine uses can be found in the system of records notice associated with this
collection of information, CNCS-10-CEO-PHRI, Personal Health and Religious Information (86
FR 6458).

Effective September 29, 2020, the operating name of the Corporation for National and Community
Service is AmeriCorps.

250 E Street SW
Washington, D.C. 20525
202-606-5000/ 800-942-2677

Reasonable Accommodation Tracking Number_____________ (will be added after form is submitted)
Person Requesting Accommodation

Date of Request

Office / Program

Work / Volunteer location

Position

Supervisor

Phone Number and Email Address

INFORMATION ABOUT YOUR RELIGIOUS ACCOMMODATION REQUEST
1. Please identify the AmeriCorps 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 AmeriCorps requirement, policy, or practice identified above.

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3. What is the accommodation or modification that you are requesting?

4. Please provide any additional information that you think may be helpful in reviewing your

request. For example:

a. How long you have held the religious belief underlying your request?
b. How does complying with the identified policy or practice conflict with religious beliefs?

5. Please list any alternative accommodations that would also eliminate the conflict between the

AmeriCorps requirement, policy, or practice and your sincerely held religious beliefs.

Requester’s Signature

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I declare to the best of my knowledge and ability that the foregoing is true and correct.

Print Name

Date

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