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Exempt Flexible Work Schedule Request 08/15/12
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Flexible Work Schedule Request for Monthly Employees
Privacy Notice: State law requires that you be informed that you are entitled to: (1) request to be informed about the information
collected about yourself on this form (with a few exceptions as provided by law); (2) receive and review that information; and
(3) have the information corrected at no charge. To request this information, contact [email protected] or (979) 862-1718.
INSTRUCTIONS This form is used by exempt employees to request a flexible work schedule which permits exceptions to the
normal hours of operation. Flexible work schedule agreements are subject to the conditions outlined in System Policy 33.06,
System Regulation 33.06.01, University Rule 33.06.01.M1, and University SAP 33.06.01M1.01. Additional information or comments
may be attached to this form where related to the terms of this flexible work schedule.
Employee Name (printed)
Employee Title
Department
Effective Starting Date*
Week One
Week Two (if different from Week One)
Begin
Time
End
Time
Lunch
Time
Daily
Hours
Begin
Time
End
Time
Lunch
Time
Daily
Hours
Mon
Mon
Tue
Tue
Wed
Wed
Thur
Thur
Fri
Fri
Sat
Sat
Sun
Sun
Total Hours
Total Hours**
I, the undersigned employee, understand the following:
Flexible work schedules are intended to last at least two consecutive months; however, my
request, if approved, may be modified, continued or discontinued at the discretion of
management at any time.
I must use paid and/or unpaid leave, including eligible holiday leave, in correlation with my
approved flex schedule for any hours I do not work. (Example: If the flexible work schedule
includes a 9-hour work day, then any paid leave for that day would be taken as 9 hours of paid
leave).
_____________________________________________________ ____________________
Employee Signature Date
APPROVED:
Supervisor Name Supervisor Signature Date
Director/Department Head Name Director/Department Head Signature Date
* System Policy stipulates a minimum timeframe of two months for flexible work schedules.
** Exempt employees may work a flexible 80-hour schedule within any consecutive two week period under
this agreement.
Distribution:
Original to Personnel File
Copy to Employee
Copy to Supervisor
Copy to Department LeaveTraq Administrator (if applicable)
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