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Flexible Work Options Request Form

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FLEXIBLE WORK OPTIONS REQUEST FORM

ACTION REQUESTED:

Temporary NTE Date:

New

Change

Cancellation

EMPLOYEE INFORMATION AND CERTIFICATION

1. EMPLOYEE NAME:

2. JOB TITLE (Series/Grade):

3. OFFICE (Division/Branch/Section/Unit):

4. DUTY STATION:

5. IMMEDIATE SUPERVISOR'S NAME:

TYPE OF FLEXIBLE WORK OPTION(S) REQUESTED:

Flexible Work Schedule

Part-time Schedule

Job Sharing

Compressed Work Schedule (CWS)

Proposed Work Schedule:

Benefits of proposed

schedule change:

Potential problems /

suggested solutions of

proposed schedule change:

Describe any equipment/

expense your arrangement

might require:

CERTIFICATION:

The employee agrees to comply with all applicable Component, DOJ, and Federal regulations, policies, and requirements. Regardless

of the trial and evaluation periods, if at any time this work option no longer serves the employee's purposes or the needs of the Agency, the work option

may be discontinued by the employee or the Agency. The attached forms define the terms of the employee's flexible work option until that option is

either modified in a written document signed by both parties, or is terminated by either party.

6. EMPLOYEE'S SIGNATURE:

7. DATE:

IMMEDIATE SUPERVISOR'S RECOMMENDATION

The employee and the supervisor have discussed this flexible work option request. At this time, the flexible work option request is:

Recommended for approval

Recommended for approval with modification (please describe):

Recommended for disapproval (state reason):

8. SUPERVISOR'S SIGNATURE:

9. DATE:

APPROVING OFFICIAL'S DECISION