Flexible Work Arrangement Form

(This is an optional form that may be used at the manager’s discretion)

Employee Information

Employee Name	Department
Employee ID	Job Title
Employee Work Phone	Supervisor Name

Flexible Work Arrangement Type

☐	Flex Schedule
☐	Flex Time or Release Time for Wellness Activities
☐	Compressed Work Week
☐	Flex Place (also complete the Flex Place Arrangement)

Work Schedule	Work Hours	Flex Place
Sunday	☐
Monday	☐
Tuesday	☐
Wednesday	☐
Thursday	☐
Friday	☐
Saturday	☐
Total Hours

I have read and understand the above arrangement. I understand that the requirements of my job remain the same as before this arrangement and my inability to meet the expectations set by my supervisor may have an adverse effect on my employment and may result in disciplinary action, including, but not limited to the immediate withdrawal of the opportunity to benefit from a flexible work arrangement. The flexible work arrangement may be re-evaluated at the discretion of either the employee or the supervisor.

________________________________________	________________________________________

Employee Name (printed)	Supervisor or Department Signature (printed)

________________________________________	________________________________________

Employee Signature	Supervisor or Department Signature

____/____/________	____/____/________

Date	Date

Date to review the Flexible Work Arrangement ____/____/________