Work Schedule Refusal Form
Use this form to formally record your refusal of a proposed work schedule. Please provide all requested details for documentation.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Human Resources
Finance
Operations
Sales
IT
Other
Position/Job Title
*
Supervisor's Name
First Name
Last Name
Date of Proposed Schedule
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Proposed Shift/Hours
*
Reason for Refusal
*
Please Select
Personal commitment
Health reasons
Schedule conflict
Insufficient notice
Other
Please provide additional details (if any)
Date of Refusal Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Refusal
Should be Empty: