Section I: To be completed by Requestor

Name: Click here to enter text.Ben El Date: Click here to enter text.Chicago ID: Click here to enter text.

Title: Click here to enter text.Department: Click here to enter text.

Supervisor: Click here to enter text.

Flexible Work Arrangement Requested:Select TypeOther: Click here to enter text.

Begin Date: Click here to enter text.End Date: Click here to enter text.

Proposed Work Hours:

Sun / Mon / Tue / Wed / Thu / Fri / Sat
From: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
To: / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

Answer all applicable questions; otherwise, indicate N/A.

  1. How many hours a week will you be working? How many days per week? Which days will be affected by the requested Flexible Work Arrangement?
  1. How will your proposed schedule sustain or enhance your ability to accomplish your responsibilities? (Please attach a copy of your job description.)
  1. What potential challenges or concerns could the requested Flexible Work Arrangement raise with faculty, colleagues, manager/supervisor, subordinates and others? How do you intend to overcome these challenges?

Click here to enter text.

  1. If you are requesting to work off-site/telecommute, are there any aspects of your role that cannot be performed off-site? What equipment will be necessary to accommodate this request and who will be providing the equipment (i.e., requestor or department)? And, if applicable, will day care arrangements be made while working off-site?

Click here to enter text.

Section II: To be completed by Supervisor

This flexible work arrangement request is:☐Approved☐Denied

If request was denied, please provide explanation.

This arrangement will be piloted for ______months, at the end of which we will review the arrangement and determine whether or not it will continue.

We will meet every ______months to discuss how this arrangement is going and to make adjustments as needed.

Please note the following:

  • If at any time this arrangement no longer serves your purposes or the needs of the organization, the arrangement may be terminated.
  • If, for any reason, the arrangement is terminated during the pilot period or at the end of this period, or at some future point in time, you will return to your former traditional work schedule/arrangement. Every effort will be made to give you at least two weeks’ notice before this change goes into effect. This document is not, and in no way is to be construed as, an employment contract. If you refuse to return to your former work schedule, the department has the ability to terminate your employment without layoff benefits. In Illinois, an employee is considered to be employed at-will, meaning he/she or the University can the terminate employment at any time and for any reason, with or without advance notice.
  • It is expected that this work arrangement will not reduce your productivity.
  • If unit needs require, there may be times when it will be necessary for you to forgo your flexible work arrangement to support unusual projects or conditions in the office. It is expected that you will make every attempt to adjust your schedule accordingly. Similarly, I will take into consideration your flexible work arrangement when scheduling meetings or gatherings that require all staff to be in attendance or when distributing workload.
  • Any information technology used through a flexible work arrangement is subject to University information-technology policies, no matter who owns the equipment. Please refer to the Eligibility and Acceptable Use Policy for Information Technology.
  • If on a compressed work week, accruals will be maintained based on the employee's average scheduled work week. For a full-day absence, employees will have accruals deducted at a rate of one-fifth the average weekly schedule of hours (e.g., 7.5 hours for a 37.5 hour workweek and 8 hours for a 40 hour workweek) for each day taken. While on a flex-time schedule, biweekly employees may have to supplement their average daily accruals with additional vacation or personal holiday time to receive their regular biweekly pay.
  • Overtime work for hourly-paid staff must be authorized in advance by the supervisor.

By signing below I acknowledge that I have read the above and discussed the terms and conditions with the undersigned supervisor and agree to all aspects of this agreement.

Requestor SignatureDate

Supervisor SignatureDate

Human Resources/Departmental ApprovalDate

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