Request For Alternative Work Schedule

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Request for Alternative Work Schedule
EMPLOYEE INSTRUCTIONS:
Complete this form and submit it to your immediate supervisor.
Name: _______________________________________ Social Security #_________________
Job Title: __________________________________ Department: _______________________
Type of request:
Flexible Work Schedule
Compressed Work Week (4/10, 9/80)
Enter the alternative work schedule you are requesting:
Pay Period Cycle
Monday
Tuesday Wednesday Thursday
Friday
Hours:
Start Time
Lunch
1/2 Hr
1/2 Hr
1/2 Hr
1/2 Hr
1/2 Hr
Week One
Length:
_______
1 Hr
1 Hr
1 Hr
1 Hr
1 Hr
Stop Time
Total Daily Hours:
Pay Period Cycle
Monday
Tuesday Wednesday Thursday
Friday
Hours:
Start Time
Lunch
1/2 Hr
1/2 Hr
1/2 Hr
1/2 Hr
1/2 Hr
Week Two
Length:
_______
1 Hr
1 Hr
1 Hr
1 Hr
1 Hr
Stop Time
Total Daily Hours:
Please complete the following questions:
Please indicate the impact the requested work schedule will have on your family/work schedule:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How will your proposed schedule sustain or enhance your ability to get the job done?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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