4 - 10 Hour Days Schedule Change Request Form
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1
2Schedule Change Request
4 – 10 Hour Days
Bridge Division
Employee Name:
Section/Location:
Requested Day Off:
Mon
Tues
Wed
Thurs
Fri
Attach interoffice memo with justification for schedule change (see attached guidelines).
I have read and understand FMS Policy 16-01.13 (requiring the use of 2 hours of annual
leave or compensatory time on holidays). I also understand that management reserves the
right to change my work schedule back to 5 – 8 hour days.
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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Parent category: Business