ALTERNATE WORK AGREEMENT REQUEST FORM
The purpose of this form is to request and document any alternate work arrangement (AWA) request and approval by the supervisor, unit leader and UTFI Human Resources. Please review UTFI human resources policy 7.20 for information on the general guidelines, expectations and eligibility.
UTFI Name
UTFI Email
example@example.com
Request initiated by:
*
Please Select
Employee
Supervisor
Employee Name
*
Employee Email
*
example@example.com
Please select only ONE that applies:
*
Please Select
Currently on AWA: request is to update information only
Confirming
Supervisor Name
*
Supervisor Email
*
example@example.com
Campus
*
Please Select
Central Services
UTIA
UTHSC
UT Knoxville
UT Martin
UT Southern
UC Foundation
Select reason for request:
*
Please Select
Flexible Schedule - compressed work week
Telecommute - alternate work location
Please provide a detailed rationale for this request
*
Duration type:
*
Please Select
Regular Assignment
Temporary Assignment
Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Anticipated End Date (as applicable for temporary schedule adjustments)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Indicate which working day(s) below requesting alternate work (out of office) to occur and proposed hours per request under the AWA.
*
Rows
Days Requested
(select all that apply)
Work Hours
if different than 8am - 5pm
Monday
Tuesday
Wednesday
Thursday
Friday
Remote Work Location Address
*
i.e. home address, alternate office address, etc.
Equipment/supply requirements and support needed
*
Rows
Provided by
Equipment Identification or Tag Number
Cost estimate (if not in inventory)
Other notes/comments
Computer
Employee
UTFI
Other - explain in comment field
Printer/Scanner
Employee
UTFI
Other - explain in comment field
Monitor
Employee
UTFI
Other - explain in comment field
iPad/SurfacePro
Employee
UTFI
Other - explain in comment field
Camera (external with microphone)
Employee
UTFI
Other - explain in comment field
Other - Keyboard, Mouse, Hotspot, general supplies
Employee
UTFI
Other - explain in comment field
Reimbursable Item (only applicable based on business need - not employee preference)
Employee
UTFI
Other - explain in comment field
Expectations of duties if outside of normal position responsibilities (i.e. special project)
Attach additional files if needed
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Employee Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Employee Signature - By signing this request form, I acknowledge and understand the terms and expectations as outlined above and in UTFI human resources policy 7.20 Alternative Work Arrangement (AWA). I understand that this AWA request and subsequent approval may be changed or discontinued at any time.
*
Supervisor Approval Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Supervisor Signature - By signing this request form as employee supervisor, you are confirming this request considers all business needs of your department/campus and employee is able to meet such needs in a remote work environment.
*
Submit
FOR HR USE ONLY
HR Approval Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
HR Approval Code
Should be Empty: