COVID-19 TELEWORK REQUEST
Fall 2020 Semester
This request should be completed by the faculty member seeking to work remotely because of the COVID-19 crisis.
To evaluate the request, this form must be completed in its entirety and proper documentation attached.
Employee Telework Information:
I am requesting to work remotely for the 2020 fall semester for the reason indicated below. DOCUMENTATION MUST
_____ I have been advised by a health care provider to self-quarantine related to COVID-19; or
_____ I am “at risk” (as an older adult or have an underlying medical condition) and, based on a medical opinion,
I wish to remain isolated; or
_____ I am caring for an individual who is subject to quarantine or isolation order related to COVID-19; or
_____ I am caring for a son/daughter whose school/place of care has been closed or provider is unavailable; or
_____ Other (please list):____________________________________________________________________________
Please return this form to Human Resources at email@example.com or via inter oce mail no later than close of business,
MONDAY, JULY 27, 2020. Completion of this form does not signify “approval.” Employee will be contacted by Department
Head once nal approval is granted.
For Oce Use Only
Received Approved Not Approved
Human Resources ____________ ____________ ____________
Supervisor ____________ ____________ ____________
Academic Dean ____________ ____________ ____________
Provost ____________ ____________ ____________
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