Alternative Work Schedule Request
(Employee initiated in accordance with Article 9 of the District/CSEA Agreement)
Hours per week:
Hours
(Start – End)
Break Length
(min. ½ hr. if applicable)
through
Hours
(Start – End)
Break Length
(min. ½ hr. if applicable)
The following contractual conditions have been met:
Employee’s Signature Date Signature, CSEA Representative Date
Supervisor's Signature of Approval Date Reviewed by Human Resources
Date
Mon Tue Wed Thu
Fri
Sat Sun
Mon Tue Wed Thu
Fri
Sat Sun
or
ONGOING
Contract months: 10 11 12
The total number of hours scheduled per week is in accordance with the assigned FTE.
The days and hours are consecutive except for an uninterrupted minimum lunch break of 30 minutes,
if applicable.
remains unchanged.
OR
will be reduced according to contractual provisions.
Shift differential compensation status
Employee Name
FTE (1.00 is full-time):
Position:
Department:
Regular Schedule
Alternative Schedule (effective dates):
CSEA review is required prior to submitting request to Supervisor. The proposed Alternative Work Schedule
shall not be implemented until all signatures have been obtained and the completed form has been submitted to
Human Resources.
2/22/2011
