Remote Work Request Form - Faculty

This Faculty form is to be completed to make a request for remote work. Your request will go directly to Human Resources for review and approval.

Name Name First Last
Email
Position
Your Direct Supervisor's Name:
Please indicate below the Vice President or Supervisor who oversees your department:
Semester requesting approval to work from home:
Have you previously been granted approval to work remotely?
When were you previously granted approval to work remotely?
Reason for Prior Approval:

Reason for Prior Approval: Age - Self Medical Condition - Self Medical Condition - Spouse or Dependent Other Other
Do the same conditions for prior approval still exist?
Reason for current request to work remotely:

Reason for current request to work remotely: Age - Self Medical Condition - Self Medical Condition - Spouse or Dependent Other Other
Please upload medical documentation for Human Resources to review and approve OR provide directly to HR in hard copy.

Attach Files

You must provide medical documentation to Human Resources. Uploaded materials will be provided to your supervisor/VP as well. If you want only HR to receive the documents, please submit hard copy.