Telework Request Form

Fill out the requested information in as much detail as possible and submit to your Department Head 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 Name

*Last Name

*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 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).

*I understand that submission of this form in no way guarantees the establishment of a flexible work arrangement. I understand the purpose of this request form is to assist me in sending a proposed arrangement to my Department Head.

I Understand

Telework Request Form

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