Fillable Request for Flexible Work Arrangement Note: Flexible work (Slippery Rock University of Pennsylvania)

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Request for Flexible Work Arrangement Note: Flexible work (Slippery Rock University of Pennsylvania)

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Request for Flexible Work Arrangement
Note: Flexible work arrangement requests will be reviewed and decisions to approve or
not approve requests will be based upon university operational needs.
Name: _________________________
Department: _____________________
Job Title: ________________________
University: Slippery Rock
Status (FT/PT): ______________
Bargaining Unit: ______________
I am requesting a flexible work arrangement because I am at a higher risk for
COVID-19
as defined by the CDC:
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
Provide medical documentation as applicable.
I am requesting the following flexible work arrangement: (e.g. schedule change, telework, work
location adjustment, etc.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Employee Signature
Date
______________________________ _________________
For Human Resources Only
Date Request Received __________
Date Supporting Documentation Received ________________
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Request for Flexible Work Arrangement Note: Flexible work (Slippery Rock University of Pennsylvania)

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Completed 26 August 2020

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