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
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