Remote or Hybrid Working Arrangement FormÂ
Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name
*
First Name
Last Name
Employee Email
*
example@example.com
Employee's Position/Title
*
Department
*
Work Arrangement Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Working Arrangement
*
Fully Remote
Hybrid with a Desk (3 or more days/week onsite)
Flexible Hybrid (2 or less days/week onsite)
Fully Onsite
Expected Schedule Details- Home vs Office
*
Rows
Start Time
End Time
Home Office
On-Site
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
On-site Working Space Arrangement
*
Permanent Desk (Only for 3+ days onsite)
Shared Space with Colleague
Reserve Desk in Hoteling Space
Other
Additional Notes
HR Business Partner Email
*
example@example.com
This proposed work arrangement & schedule will not incur a negative impact on the business.
*
I agree and support this arrangement.
The working arrangement will not cause overtime or additional workload.
*
I agree that this arrangement will not cause unnecessary OT or additional work.
Employee performance can be monitored/tracked during work arrangement.
*
Yes, I will be able to effectively monitor employee performance under this agreed arrangement.
Approval of the Request
*
I approve all aspects of this working arrangement request.
Additional Comments/Considerations
Supervisor Name
*
First Name
Last Name
Supervisor Email
*
example@example.com
Supervisor Initials or Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: