Washington State University - Faculty Modified Duties Request Form

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WASHINGTON STATE UNIVERSITY
Faculty Modified Duties Request Form
This form is to be used in accordance with the Faculty Modified Duties Guidelines.
Employee Information
Print Name
WSU ID Number
College/School/Area
Department
Campus Address
Campus Phone
Requested period of Modified Duties (specific or approximate) __/__/__ through __/__/__
Reason for Request
I am the primary care giver for a family member who requires assistance due to a serious health condition.
I am the primary care giver for a family member who requires assistance as the result of being injured while in
active duty for the armed services.
I am the parent or in a parental role and share primary care giving responsibilities for a child who has recently
entered the home.
Please specify the reason for your request if the above selections are not appropriate
I understand that I will continue to perform a full work load while participating in the modified duties process, if
approved. In the event I find I need to reduce my work load, and may not be able to perform the identified duties due to
the need to work a reduced scheduled, I may need to pursue this as a leave request and will contact HRS immediately.
Attached is a plan of proposed modified duty activities.
The plan  has  has not been discussed with my Department Head/Chair/Director/Dean.
Attached is the medical information supporting my request
.
Medical records are not to be submitted or maintained at the department level. All medical records are to be
submitted to Human Resource Services.
Forms for medical leave can be found
at:
hrs.wsu.edu/Disability Services
or by calling (509) 335-4521.
______________________________________________
__________________
Employee’s Signature
Date
 Approve  Deny
________________________________________
__________________
Department Head/Chair/Director
Date
 Approve  Deny
________________________________________
__________________
Dean/Vice President
Date
 Approve  Deny
________________________________________
__________________
Provost
Date
Please submit completed form and materials to:
HRS - 139 French Administration - campus zip 1014 - Fax 509-335-1259
September 2012

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