Form Ct-Hr-7c Request For Schedule Change Under The Voluntary Schedule Reduction Program (Vsrp) Page 2

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Part II – To be completed by the supervisor/manager/director of employee submitting request
__ I RECOMMEND APPROVAL OF THIS REQUEST.
__ I AM UNABLE TO RECOMMEND APPROVAL OF THIS REQUEST BECAUSE:
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________
_________________
Supervisor’s/Manager’s/Director’s Signature
Date
Part III – To be completed by the Agency Head/Designee
U
.
NPAID TIME OFF SHALL NOT BE GRANTED IF THE EFFECT WOULD BE TO INCUR OVERTIME COSTS
I have reviewed this request and have researched records to determine whether or not (a.) the employee requesting leave
under the VSRP meets the definition of ‘permanent employee’ as provided by C.G.S. § 5-196, (b.) the days/hours
requested meet the criteria established by Section 5-248c-1(c) of the Personnel Regulations, (c) the requested schedule
will not result in the employee falling below the threshold for eligibility for health insurance benefits. My findings are as
follows:
C
:
IRCLE ONE
___ A
___ A
LL CRITERIA ARE MET
LL CRITERIA ARE NOT MET
Further, if the employee is currently serving a promotional working test period, I have advised the employee that leave
taken under the VSRP will not be counted toward completion of that working test period.
__ I APPROVE THIS REQUEST.
__ I AM UNABLE TO APPROVE THIS REQUEST BECAUSE:
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________
_________________
Agency Head’s/Designee’s Signature
Date
F
S
P
(
): General
Federal
Other: __________
UNDING
OURCE OF
OSITION
CIRCLE
T
A
H
W
P
:
OTAL
NTICIPATED
OURS
ITHOUT
AY
E
’
H
R
P
:
MPLOYEE
S
OURLY
ATE OF
AY
T
A
S
:
OTAL
NTICIPATED
AVINGS
cc: Personnel File
This form provided by the Department of Administrative Services

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