Fillable COVID-19 TELEWORK REQUEST (Northwestern State University)

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COVID-19 TELEWORK REQUEST (Northwestern State University)

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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:
Employee Name:
CWID#:
Email Address:
Phone:
Job Title:
Department:
Department Head:
I am requesting to work remotely for the 2020 fall semester for the reason indicated below. DOCUMENTATION MUST
BE ATTACHED:
_____ 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):____________________________________________________________________________
___________________________________________________________________________________________
EMPLOYEE DATE
Please return this form to Human Resources at covid19hr@nsula.edu or via inter oce 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.
7-15-2020
For Oce Use Only
Received Approved Not Approved
Human Resources ____________ ____________ ____________
Supervisor ____________ ____________ ____________
Academic Dean ____________ ____________ ____________
Provost ____________ ____________ ____________
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COVID-19 TELEWORK REQUEST (Northwestern State University)

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Completed 23 July 2020

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