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• Work From Home Request Form

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• Date
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• Employee Name*
• Employee ID#*
• Department*
• Position/Title*
• Employee Phone*

  --
• Employee Email*
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• WFH Start Date*
• WFH End Date (if known)
• Proposed Work Schedule

  	Start Time	End Time	Lunch	Break
  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
  Saturday
  Sunday

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• Reason for Work From Home Request.*

• ---

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• Supervisor Name*
• Phone

  --
• Supervisor Email*
• Can the employee's performance be monitored while working from home?*

  Yes No
• Will the proposed work from home schedule affect the operations negatively?*

  Yes No
• Will the WFH schedule cause overtime or additional workload for the employee or other team members?*

  Yes No
• Is necessary office equipment currently available for employee's home office?*

  Yes No
• Additional Comments
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• Request Decision*
  Approved Denied

  Reason for Denial
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• Employee Signature*
• Supervisor Signature*
•