UVM At-Risk Employee Remote Work Request
Temporary in Response to COVID-19
Use this form if you:
•
Meet CDC guidelines for having an increased risk for severe illness from COVID-19
Live with or care take of an individual identified by the CDC as having an increased risk for severe illness from COVID-19
Have concerns related to COVID-19 and pregnancy
•
•
Form Instructio
ns
To request or extend existing telework, complete this form and send it to your supervisor for consideration. Management
must agree work can be done remotely, and the request must be approved by the Dean’s or applicable VP’s Office. A decision
will be provided to you in writing by your supervisor. The Dean’s or VP’s Office will retain a copy of your request and telework
plan. If telework is approved, please complete or revise a Temporary Telework Agreement. If you have any requests for ADA
Accommodations other than remote work, due to your medical condition, please contact the ADA Coordinator at
accessibility@uvm.edu or 656-0945.
Note to Management: Before denying a request, please consult with your servicing Labor and Employee Relations Coordinator.
Employee Information
Employee Name:
Employee ID Number:
Department:
Position:
Describe Your Work Request (do not include information about your medical condition or situation)
Request Approved or Denied (Administrative use only. If request is denied, provide explanation.)
Signatures and Dates
Employee:
Supervisor:
Dean's / VP's Office:
