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 *

Month Day Year
Date
Name *

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

Area Code Phone Number
Email
example@example.com
Telework Start Date *

Month Day Year
Date
Telework End Date *

Month Day Year
Date
Expected return to campus date

Month Day Year
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 *

Month Day Year
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