Voluntary Work Schedule Adjustment Agreement - Michigan Page 2
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2STATE OF MICHIGAN
VOLUNTARY WORK SCHEDULE ADJUSTMENT AGREEMENT
Name_________________________________ ID # ___________ Classification______________ Bargaining unit______
Dept _____________ Work location___________________________ TKU______ Work phone_____________________
In accordance with the voluntary work schedule adjustment agreement, I request the following voluntary change in
conditions of my employment. I understand that my supervisor and I must agree in writing on my work schedule.
___ Plan A Single pay period in lieu of annual leave use
(up to 40 hours in a single pay period per fiscal year)
PPE____________
Total hours reduction for the pay period_____
Proposed work schedule (hours in pay status per day)
Total
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Hrs/PP
___ Plan A Multiple pay period reduction of hours
(limit 16 hours reduction per pay period)
Start date_______________ End date_____________ Total hours reduction per pay period _______
Proposed new work schedule, (hours in pay status per day)
Total
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Hrs/PP
____Plan C Unpaid leave of absence
(Maximum period 3 months)
Unpaid leave of absence beginning ________________ and ending on _________________
By signing this Plan C agreement I understand that during this leave of absence I may elect to continue my present State-
sponsored group insurance coverage by pre-paying my present share of the premium prior to departure.
Cancellation of Agreements: An agreement under this program can be terminated by the department upon ten (10) working
days’ notice in writing to the employee. Such termination shall not be grievable. The employee may terminate this agreement
upon ten (10) working day’s notice in writing.
Employee’s Signature_______________________________ Date________________
A description of the details of each Plan, including eligibility requirements can be found on the reverse of this Agreement.
Approved___ Denied*___
___________________________ ________________________ _____________________
Supervisor Name
Signature
Date
Approved___ Denied*___
___________________________ ________________________ _____________________
Division/Bureau Director Name
Signature
Date
Approved___ Denied*___
___________________________ ________________________ _____________________
Appointing Authority Name
Signature
Date
*Please attach brief explanation if denied
For Personnel Office Use Only
I__I__I__I__I__I__I__I
I__I
I__I__I
I__I__I__I__I__I__I__I__I
Employee ID Number
Plan Code Hrs. Deferred
Ending Date MO DA YR
Complete in triplicate: One copy to be retained by employee, one by the supervisor and one forwarded to Human Resources.
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