Request an Alternate Work Schedule

Before completing this form, please review the Alternate Work Location (AWL) Policy.

Name Name First Last
Best Contact Number Best Contact Number - ### - ### ####
Title
Department / Division
Supervisor Name Supervisor Name First Last
Senior Vice President (SVP) Name Senior Vice President (SVP) Name First Last
Current Work Location
Proposed Work Location
After reading the policy, I am requesting to work remotely:

After reading the policy, I am requesting to work remotely: 1 day per week Hybrid 100%
Do you work in a student-facing or employee-facing position? If you're not sure, please consult the Alternate Work Location (AWL) Policy, which defines these terms.

Do you work in a student-facing or employee-facing position? If you're not sure, please consult the Alternate Work Location (AWL) Policy, which defines these terms. Yes No
Requested Effective Date Requested Effective Date / MM / DD YYYY
Is this a temporary request?

Is this a temporary request? Yes No
Telecommute / Alternative Work Arrangements
Why are you requesting this arrangement?
What positive outcomes do you anticipate as a result of this arrangement? Please include how this arrangement may benefit your department and Jacksonville University.
Describe how this change may impact your external stakeholders. Include proposed solutions to challenges.
Describe how this change may impact your internal stakeholders and colleagues. Include proposed solutions to challenges.
How will you communicate with your supervisor, colleagues, and clients?
Additional comments
Signature
If approved, do you promise to follow the remote work policy, and do you understand that failure to do so could result in the revocation of the remote work agreement? *

If approved, do you promise to follow the remote work policy, and do you understand that failure to do so could result in the revocation of the remote work agreement? I agree.
Digital Signature Digital Signature * Title First Middle Last Suffix

Request an Alternate Work Schedule

Request an Alternate Work Schedule

Telecommute / Alternative Work Arrangements

Signature