Human Resources

Dana-Farber Cancer Institute

440 Brookline Avenue
Boston, Massachusetts 02215-5450
Email: employeerelations@dfci.harvard.edu

Request For a Religious Accommodation Form

Last Updated: July 2021

To be completed by Workforce Member:

 All questions must be answered thoroughly
 Completed requests should be submitted to: employeerelations@dfci.harvard.edu

1. Please identify the reason for request (e.g. job or schedule conflict, dress/appearance policy
conflict, time to pray):

2. Please identify the requested religious accommodation. Please be specific and include
information regarding what aspect of your job duties or responsibilities you are seeking to
modify and for how long you will require the accommodation:

a. Describe the change you are requesting to make your job duties or responsibilities:

b. For how long will you require this accommodation?

c. Are there specific days/shifts needed as an accommodation?

3. Please identify the religion on which you are basing your request:

4. Please explain how the requested accommodation is based on or relates to your religious
practice or observance:

5. Please identify any associated practices, rituals, or observances you follow to adhere to this
religious practice or observance.
6. Please identify when you first embraced the belief or practice on which your reasonable
accommodation request is based. Also identify when, where, and how you adhered to this
practice or observance.

7. Can you provide any statements, affidavits or other documents from your religious leaders
or others knowledgeable about your religion to support your request?

8. Can you provide any statements, affidavits or other documents from other individuals who
may have observed your past adherence to this practice?

I understand that the DFCI may not be able to grant my requested accommodation but that the
DFCI will attempt to provide a reasonable accommodation for my sincerely held religious beliefs
or practices, provided that doing so does not create an undue hardship on the DFCI.

I hereby attest that the above statements are true and accurate to the best of my knowledge:

Workforce Member Name (printed):

Workforce Member Signature:

Date:

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To be completed by Human Resources:

1. Describe the impact (if any) of Workforce Member’s suggested accommodation:

2. Workforce member’s requested accommodation accepted?  Yes  No

3. Alternative accommodations (list in order of preference):

a.
b.

Discussed with workforce member on:

1. Accommodation agreed upon (please be specific and include duration and timing):

2. If no agreement on an accommodation, please explain:

Signature and Title (Supervisor or Human Resources):

Date: