SIUE ALTERNATIVE WORK SCHEDULE PROPOSAL

Employee Name	Supervisor Name
Job Title	Exempt Nonexempt
Department	Date Submitted

Part I: ALTERNATIVE WORK SCHEDULE REQUESTED

Variable work schedule for a fixed duration	Duration of Proposal (maximum of 6 months if requested by employee):
Compressed workweek	Start Date:
Continuation of Alternative Work Schedule	End Date:

PART II: CURRENT AND PROPOSED SCHEDULES

Current Schedule	Proposed Alternative Work Schedule
Days	Start and Stop Times

(including a minimum ½ hour unpaid meal period)	Days	Start and Stop Times

(including a minimum ½ hour unpaid meal period)
Sunday	Sunday
Monday	Monday
Tuesday	Tuesday
Wednesday	Wednesday
Thursday	Thursday
Friday	Friday
Saturday	Saturday
Total Hours:	Total Hours:

Please indicate whether you are taking thirty (30) minute or one (1) hour unpaid meal periods:

PART III: WORK ISSUES TO BE CONSIDERED

How will this proposed alternative work schedule sustain or enhance your ability to complete your work responsibilities?

PART IV: EMPLOYEE SIGNATURE

I have read, understand, and agree to the alternative work schedule procedures. I understand that it is my responsibility to make my alternative work schedule a success and that my Supervisor, Department Head, Vice Chancellor and/or the University have the right to discontinue this schedule at any time--with advance notice, if possible.

Employee Signature	Date

PART V: AUTHORIZATION OF SUPERVISOR

I have reviewed this alternative work schedule proposal with the employee.

This proposal is:	Approved	Denied

Supervisor Signature	Date

I have reviewed this alternative work schedule proposal with the supervisor.

This proposal is:	Approved	Denied

Dean/Director Signature	Date

This proposal is:	Approved	Denied

Vice Chancellor Signature	Date

PART VI: OFFICE OF HUMAN RESOURCES REVIEW

This proposal is:	Approved	Denied

Director of Human Resources Signature	Date

Acknowledgements:

The University acknowledges and credits the following universities in the development of this document: The University of West Florida.

08/06/2015

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Joyree Chura

2015-08-06

Chura, Joyree

Southern Illiniois University Edwardsville