Request For Alternative Work Schedule (4/10) Form
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1Date:
To:
From:
Subject: Request for Alternative Work Schedule (4/10)
I request consideration and approval to participate in the following alternative work schedule:
4/10 (Four ten-hour days per week)
Effective dates: Beginning:
through
WEEK 1
Monday
Tuesday
Wednesday
Thursday
Friday
Start Time:
End Time:
(includes 30 minute
unpaid lunch)
Hours Worked or
Charged:
(
)
See your Manager for available start/end times to ensure department coverage.
I understand that this schedule may be modified or cancelled in accordance with the Alternative
Work Schedule Policy. Participation is not an employee right or benefit and may be discontinued
by either party with 30-day notice for monthly employees or one-week notice for weekly
employees.
__________________________________________________
Employee Signature
Date
__________________________________________________
Approved
Supervisor Signature
Date
Not Approved
__________________________________________________
Approved
Division/Section Head Signature
Date
Not Approved
__________________________________________________
Approved
Workforce Resources & Development Signature
Date
Not Approved
Send completed form to Records Office at M.S. 124
Created June 2007
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Parent category: Business