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Work From Home Request Form
1
Request Date
-
Date
Month
Day
Year
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2
Employee Name
First Name
Last Name
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3
Email
example@example.com
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4
Employee ID
1
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5
Position/Title
2
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6
Department
3
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7
Work From Home Start Date
-
Date
Month
Day
Year
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8
Work From Home End Date
-
Date
Month
Day
Year
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9
Proposed Schedule Details
Start Time
End Time
Monday<br>
Row 0, Column 0
Row 0, Column 1
Tuesday
Row 1, Column 0
Row 1, Column 1
Wednesday
Row 2, Column 0
Row 2, Column 1
Thursday
Row 3, Column 0
Row 3, Column 1
Friday
Row 4, Column 0
Row 4, Column 1
Saturday
Row 5, Column 0
Row 5, Column 1
Sunday
Row 6, Column 0
Row 6, Column 1
Monday<br>
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Start Time
Row 0, Column 0
End Time
Row 0, Column 1
Start Time
Row 1, Column 0
End Time
Row 1, Column 1
Start Time
Row 2, Column 0
End Time
Row 2, Column 1
Start Time
Row 3, Column 0
End Time
Row 3, Column 1
Start Time
Row 4, Column 0
End Time
Row 4, Column 1
Start Time
Row 5, Column 0
End Time
Row 5, Column 1
Start Time
Row 6, Column 0
End Time
Row 6, Column 1
1
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10
Purpose/Reason for Working at Home
4
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11
Employee Signature
Clear
5
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12
Supervisor Name
First Name
Last Name
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13
Proposed work from home schedule will not affect the operations negatively.
Yes
No
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14
The practice will not cause overtime or additional workload.
Yes
No
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15
Employee performance can be monitored/tracked during work from home practice.
Yes
No
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16
Approval of the Request
The request is approved.
The request is denied.
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17
Additional Comments/Considerations
6
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18
Date
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Date
Month
Day
Year
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19
Supervisor Signature
Clear
7
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