AUTHORIZATION TO MODIFY EMPLOYEE WORK SCHEDULE
FOR SALARIED NON-EXEMPT EMPLOYEES
This form is to be utilized to document modifications in work schedules and/or Overtime earned.
Completion of this form is required for prior approval of the accrual of all overtime for salaried non-exempt
employees for hours worked over 40 in a work week. The workweek begins each Sunday morning at 12:01
a.m. and ends on the following Saturday at 12:00 a.m. Overtime pay will be paid at one and one-half hours
for each hour worked over 40. Actual hours worked should be recorded on the bi-weekly leave report. For
questions regarding overtime provisions please contact your supervisor or the Office of Human Resources at Ext.
1508.
This form is for departmental use only. Please do not forward to Human Resources.
Employee Name: Banner ID:
Position Title: Department:
Pay Period Begin Date: Pay Period End Date:
Number of Additional hours to be worked: Date of Additional Work:
Overtime Earned: □ Yes □ No Number of Overtime hours:
Employee schedule adjustment: Date(s): Time(s):
Employee acknowledges adjustments to the workweek: □ Yes □ No Employee Initials:
Schedule Adjustment or Overtime is necessary for the following reason(s):
Department Head Approval:
□ Approved □ Disapproved
Signature: ____________________________________________ Date: _______________________________
Administrative Officer Approval: (Optional)
□ Approved □ Disapproved
Signature: ____________________________________________ Date: _______________________________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
