FCC Form 5652 Request for Religious Accomodation

OMB Control No. 3060-XXXX

Est. Avg. Burden per Response: 2.5 hours

The Office of Workplace Diversity

Federal Communications Commission

Not yet approved by OMB

REQUEST FOR RELIGIOUS ACCOMMODATION This record must be maintained separate and apart from personnel file
1. APPLICANT’S OR EMPLOYEE’S NAME APPLICANT’S OR EMPLOYEE’S PHONE # APPLICANT’S OR EMPLOYEE’S EMAIL	DATE OF REQUEST SUPERVISOR AND PHONE # EMPLOYEE’S OFFICE
2. TYPE OF ACCOMMODATION OR MODIFICATION REQUESTED, IF KNOWN (Be as specific as possible, e.g., schedule change, dress/appearance code exception, exception to scheduling requirement (working on Sabbath prohibited by employee’s religious belief), etc.)
3. REASON FOR REQUEST: Please identify the FCC requirement, policy, or practice that conflicts with your sincerely held religious observance, practice, or belief (hereinafter "religious beliefs").
4. SPECIFIC INFORMATION REGARDING REQUEST: Please describe the nature of your sincerely held religious beliefs or religious practice or observance that conflicts with the EEOC requirement, policy, or practice identified above
5. ALTERNATIVE ACCOMMODATIONS: List any alternative accommodations that also would eliminate the conflict between the EEOC requirement, policy, or practice and your sincerely held religious beliefs.
6. VERIFICATION: The Federal Communications Commission (FCC) may ask for other information as needed to determine if you are legally entitled to an exception. Submission of this form constitutes a declaration that the information you provide is, to the best of your knowledge and ability, true and correct. Any intentional misrepresentation to the Federal Government may result in legal consequences, including termination or removal from Federal Service.
________________________ __________________________ ___________________________ APPLICANT SIGNATURE DECIDING OFFICIAL NAME DECIDING OFFICIAL SIGNATURE
5. FCC‐ACC No.: (Religious Accommodations Liaison will assign number)

Privacy Act Statement

Authority: Title VII of the Civil Rights Act of 1964, as amended, as implemented through 29 C.F.R. §§ 1605 and 1614.

Purpose: The principal purpose for collecting this information is to permit the Federal Communications Commission (FCC) to assess whether individuals are entitled to a religious accommodation. Additionally, this information is being collected and maintained by the FCC to record and track requests for religious accommodation by individuals, their provision, and the disposition of such requests. Information collected in connection with a request for religious accommodation is confidential and may be shared with Agency officials or Agency contractors only when those other individuals need to know the information to make determinations on a religious accommodation request or to assist the Religious Accommodations Liaison in making such a determination.

Routine Uses: This information may be disclosed outside of the FCC pursuant to the Routine Uses described in the FCC/OWD-1, FCC Workplace Accommodation Requests, System of Records Notice (SORN), posted at https://www.fcc.gov/managing-director/privacy-transparency/privacy-act-information. Such disclosures include to the Department of Justice when necessary for litigation or adjudication, to officials of labor organizations upon receipt of a formal request, and to other federal agencies when necessary to assist with response to a breach of information.

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information, the FCC may not provide you with an accommodation, and you may not receive important information.

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT

We have estimated that each response to this collection of information will take X hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD‐PPM, Paperwork Reduction Project (3060-XXXX), Washington, DC 20554. We will also accept your comments via the Internet if you send them to pra@fcc.gov. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS. Remember ‐ you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060‐XXXX.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104‐13,

FCC Form 5652

2024

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