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
Date
Name*

First NameLast Name
Department Name (if applicable)
Phone Number*

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

MonthDayYear
Date
Telework End Date*

MonthDayYear
Date
Expected return to campus date

MonthDayYear
Date
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
Date
E-Signature*

Clear
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