Fillable State of Emergency Work Arrangements Policy (Durham Technical Community College)

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State of Emergency Work Arrangements Policy (Durham Technical Community College)

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State of Emergency Work Arrangements Policy
Refusal to Work Form
Employee Name: ___________________________________________
Employee Position Title: ___________________________________________________________________________
Employee Department and Division: _________________________________________________________________
Employee ID Number: _______________________________________
Employee Contact Numbers (office extension and a non-work number): _____________________________________
Employee Email Address: _____________________________________
Employee Category:
☐ Full-time Staff
☐ Part-time Staff
☐ Adjunct Faculty
☐ Temporary Employee
☐ Due to my role, I am considered Essential Personnel.
If applicable, please document any existing extenuating circumstances related to your refusal to work.
I understand that submission of this form indicates my refusal to work during the duration of the
________________ emergency. I further understand that, absent the College’s acceptance of my extenuating
circumstances as just cause for my refusal to work, I will be required to use, and report, leave in accordance
with College policy. If I am classified as Essential Personnel, I understand that, absent extenuating
circumstances, my refusal to work and/or report to my worksite may subject me to disciplinary action, up to
and including termination.
By printing your name below and submitting this form via College email, you are attesting to your
understanding of the contents contained herein.
Employee Printed Name: ________________________________________________ Date: ____________________
By printing your name below, you are attesting to your review and acceptance of this form for the
employee named above.
Supervisor Printed Name: ________________________________________________ Date: ____________________
Supervisor Title: __________________________________________________________________________________
Division Head Printed Name: ______________________________________________ Date: ____________________
Division Head Title: ________________________________________________________________________________
Revised 4/8/2020
FOR HUMAN RESOURCES USE ONLY
☐ The employee did not cite any extenuating circumstances and must use, and, report leave.
☐ The employee’s extenuating circumstances are accepted, and the employee is not required to use or report
leave.
☐ The employee’s extenuating circumstances are not accepted, and the employee is required to use and
report leave.
☐ The employee is classified as Essential Personnel. The employee did not cite extenuating circumstances, or
their extenuating circumstances were not accepted. The Executive Director of Human Resources will
contact the employee and the supervisor within two (2) business day to discuss disciplinary action.
By printing your name below, you are attesting to your review of this form and issuing the determination
noted above.
Executive Director, Human Resources Printed Name: ________________________________ Date: ______________
Revised 4/8/2020
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State of Emergency Work Arrangements Policy (Durham Technical Community College)

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Completed 1 October 2020

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