STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DEPARTMENT OF ADMINISTRATION
Division of Human Resources
Teleworking Request Form
Created 06/28/18 **Employees are selected to participate at the sole discretion of management**
To be completed by requesting employee. Please Print.
Employee Name:
Employee Job Title:
Division:
Director Name:
I would like to Telework beginning on: _________________________________________
MM-DD-YYYY
I would like to Telework on the following days: (check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
My teleworking hours will be: (scheduled breaks to be taken within this time)
I believe the following task(s) that I am currently assigned might be appropriate for teleworking:
I have read the State’s current Teleworking Policy and related documents and agree to comply with all
provisions in these documents.
Attached is my completed Telework Agreement which will need to be reviewed and approved along with
this request form by my Manager/Supervisor, the Agency Division Director, and the Executive Director of
Human Resources/Personnel Administrator.
Employee Signature
Date
click to sign
signature
click to edit
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