COVID-19 Work from home Request

Work from Home Request Form

COVID-19
Please complete this form to request arrangments to telework on or after May 25, 2020.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Department Name (if applicable)
Phone Number

Area CodePhone Number
Email
example@example.com
Telework Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Telework End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected return to campus date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe the Proposed Telework Schedule i.e. Mon-Fri 7:30am-4:00pm
Purpose/Reason you are requesting to work from home.
Any other information we should know?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
E-Signature
Thank you. Your request will be reviewed. Human Resources will follow up with you within 1-2 business days.
Should be Empty:

Work from Home Request Form