Telework Request Form

Fill out the requested information in as much detail as possible and submit for review. Note: If this request is related to a medical leave or disability accommodation, do not complete this form. Contact Human Resources for guidance at 508-799-1130 or benefits@worcesterma.gov.

First

Middle

Last

Email Address

Position Title

Department

Select the types of flexibility you are interested in:

Indefinite Change in Arrival and/or Departure Time

Temporary Change in Arrival and/or Departure Time

Work Remotely on a Consistent Basis

Work Remotely on an Occasional Basis

What is your current work schedule?

What changes would you like to make to this schedule (such as arrival time, departure time and/or work location)? Please be specific.

When would you like these changes in your hours/work location to begin? If this is a temporary request, when would you like the arrangement to end?

What positive outcomes do you anticipate as a result of this arrangement? When answering, focus on workplace specific outcomes (such as your ability to perform your work).

Describe in detail how this schedule change may impact those you serve (customers/members of the public). Include proposed solutions to any identified challenges.

Describe in detail how this schedule change may impact those you work closely with (Department Head, supervisor, colleagues, collaborators, etc.). Include proposed solutions to any identified challenges.

Final comments and/or questions you would like to share with your supervisor as they consider your request (related to your skills, performance, work responsibilities, or other workplace matters).

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Telework Request Form

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