Flexible Work Arrangement Application

Quinnipiac University Flexible Work Arrangement Application Employee Name: Department/School: Title: Supervisor: Position Type: Date Requested: Type of proposed flexible work arrangement being requested: (For definitions of each option, please refer to the Flexible Work Arrangement Policy.) Check all that apply Flextime Telecommuting If requesting a flextime arrangement, please complete the chart below: Current Schedule Proposed Schedule Total hours worked Monday Tuesday Wednesday Thursday Friday If requesting a telecommuting arrangement, please complete the chart below. If you are proposing a specific telecommute weekday, please indicate according to hours in the chart. Telecommute work hours On-campus work hours Total hours worked Monday Tuesday Wednesday Thursday Friday Conditions of Proposed Flexible Work Arrangement Please complete the following questions, as applicable: 1. Describe your primary job responsibilities: 2. Please describe how this arrangement will allow you to fulfill job duties and meet the business needs of the school/department: 3. Do you have a location that is suitable for working from home without distractions or other obligations? Please describe. As a telecommuting employee, I acknowledge that 100% of my workday must be dedicated to my role at the University. I acknowledge that this arrangement is not intended to serve as a substitute or replacement for child or adult care. I acknowledge that if children or adults need primary care during my work hours, alternative arrangements must be made to provide care for the said individual. I understand that Quinnipiac is not obligated to approve a proposed flexible work arrangement for any employee. This decision is made at the discretion of my supervisor. I understand my supervisor may restrict or adjust my flexible work arrangements when workload or other conditions require such restrictions or adjustments. I understand that any incomplete annual performance review will render the flexible work arrangement null and void. Generally, the supervisor should give at least two weeks’ notice in advance of ending or changing an arrangement, business needs permitting. Employee Signature and Date: Supervisor Signature: Approved Effective Date: Not Approved Reason for not approving: ----------------------------------------------------------------------------------------------------------------------------------------------------------- For 100% Telecommuting requests only: MANAGEMENT COMMITTEE MEMBER APPROVAL Name: Signature: Date: HUMAN RESOURCES APPROVAL Name: Signature: Date: Next Steps: If approved, submit the Flexible Work Agreement (available on MyQ) to your Employee & Labor Relations Associate. If not approved, Supervisor should keep a copy of this application in their files. Stephanie Mathews: Academic Innovation & Effectiveness (including Libraries), Athletics, Cultural and Global Engagement, Human Resources, School of Health Sciences, School of Law, School of Nursing, Information Services, Provost, Public Safety, Registrar, Student Affairs & Residential Life Ed Remillard: Enrollment Management (Admissions & Financial Aid), College of Arts & Sciences, Development & Alumni Affairs, Facilities, Finance, IMC, Polling, Ireland’s Great Hunger Museum, One Stop, School of Business, School of Communications, School of Education, School of Engineering, School of Medicine.

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