Work From Home Request Form
Request Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name
First Name
Last Name
Email
example@example.com
Employee ID
Position/Title
Department
Work From Home Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Work From Home End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Proposed Schedule Details
Rows
Start Time
End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Purpose/Reason for Working at Home
Employee Signature
Supervisor Name
First Name
Last Name
Proposed work from home schedule will not affect the operations negatively.
Yes
No
The practice will not cause overtime or additional workload.
Yes
No
Employee performance can be monitored/tracked during work from home practice.
Yes
No
Approval of the Request
The request is approved.
The request is denied.
Additional Comments/Considerations
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor Signature
Submit
Should be Empty: