REQUEST FOR FLEXIBLE WORK SCHEDULE

Employee name: ___________________Date:_________

Position: _____________________Department: _______________________

Flexible work schedule requested:

_____ Part-time schedule _____ Compressed work weeks

_____ Flextime _____ Job sharing

_____ Telecommuting _____ Other

Complete for your current work schedule and the work schedule requested:

Days/Hours (Current) Days/Hours (Request) On-site Off-site

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Total:

How will your requested work schedule sustain or enhance your ability to get the job done?

Describe any potential problems that could be encountered by your requested schedule with your:

Manager:

Co-workers:

External customers:

Internal Customers:

How do you propose overcoming any potential problems you noted in the previous section?

Describe any additional equipment/expense that your requested work schedule might require. Detail any short- or long-term cost savings that might result from your requested schedule to offset these expenses.

What reasonable results and measurements would you propose for your manager to assess how your performance in your requested schedule is meeting expectations? Be as quantitative as possible.

What review process with your manager do you propose for monitoring and improving your requested work schedule? Are there measurable outcomes to use in this review process?

Manager completes this section:

Request for a flexible work schedule is _____ approved or _____ declined. If declined, explain why:

If approved, effective beginning date of flexible work schedule:

Managers signature: ______________________________ Date: ___________

Employees signature: _____________________________ Date: ___________

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