administrative-regulations-manual-rev-8-4-2022.pdf

R EQUEST FOR A CCOMMODATION FOR R ELIGIOUS O BSERVANCES This form must be submitted by the student to the instructor as soon as possible and, except in unavoidable situations, at least one (1) week in advance of a planned absence. Students must submit a separate form to each course instructor the accommodation request will impact. The instructor and student are responsible for signing this form once the religious observance accommodation is determined; it is recommended that both parties retain a signed copy for their records. Student ID Number: Date Submitted:

MM

DD

YY

Name:

Campus Location:

CCAC Email Address:

Circle One:

Year:

Fall

Spring

Summer

Term of Accommodation Requested:

Department/Instructor’s Name:

Course Number, Name and Section:

A CCOMMODATION FOR O BSERVANCE D URING THE T ERM

Date of Absence

Observance

Requested Accommodation Agreed Upon Accommodation

It is understood that this information will be treated in a confidential manner, except to the extent that the information is false, fraudulent, required to be used in any claim of academic misconduct against the student or required to be disclosed to defend CCAC in any claim or potential claim involving the student or the

suspicion of fraud. Student Signature:

_______________________________

Date:

_______________________________

Instructor Signature:

_______________________________

Date:

_______________________________

CC: Office of Diversity, Equity & Inclusion (ODEI)

Appendix B

Made with FlippingBook Learn more on our blog