5 - 8 Hour Days Schedule Change Request Form

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Schedule Change Request
5 – 8 Hour Days
Bridge Division
Employee Name:
Section/Location:
Date of Last Schedule Change:
Attach interoffice memo with justification for schedule change (see attached guidelines).
Anticipated Start Date:
(must be on a Sunday)
Employee Signature:
Date:
Completed by Employee’s Supervisor
Does the employees’ request meet the guidelines?
Yes
No
Employee’s Supervisor
Date
Assistant State Bridge Engineer
Date
APPROVED:
State Bridge Engineer
Date
Effective Date:
Rev. 07-2005
Original – Employee’s Personnel File

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