ALTERNATIVE WORK SCHEDULE REQUEST
Name_______________________________________ Department____________________________
Present workday from _______ a.m. to _______ p.m. Pass Days _____________________________
(If other than Sat/Sun)
Option Requested: Staggered Hours Compressed Workweek
Flex Time Compressed Pay Period
Under the above option, my proposed work schedule would be as follows:
Time period requested: From: __________________________ through __________________________
Date Date or Indefinite
(Note: Compressed workweek or pay period options must begin on the first day of a pay period
and end on the last day of a pay period.)
__________________________________________ _______________________
Signature Date
This section is required for employees who do not report directly to a management supervisor.
I have met with the employee and I support this request do not support this request
Reasons, if not supported_______________________________________________________________
________________________________________________ _______________________________
Immediate Supervisor Date
I do support this request
I do not support this request. Reasons: _________________________________________________
________________________________________________ _______________________________
Department Supervisor Date
ALL REQUESTS, WITH OR WITHOUT SUPERVISORY SUPPORT, MUST BE SUBMITTED TO THE
MANAGEMENT SUPERVISOR FOR COMPLETION OF THE ENTIRE FORM.
The above request meets the appropriate guidelines for Alternative Work Schedule.
________________________________________ __________________________
Human Resources Office Date
_____ Approved—Time Period ___________________________ to _____________________________
Date Date or Indefinite
_____ Denied—Reasons: _______________________________________________________________
________________________________________ __________________________
Management Supervisor Date
________________________________________________ ________________________________
Appropriate Vice President Date
Distribution: Employee, Human Resources, Supervisor(s)
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