Sick Leave Pool Transfer - Home - Delta State University



381444583820COVID-19Work From Home Request400000COVID-19Work From Home RequestDelta State UniversityOffice of Human Resources276225173355Employee Information00Employee InformationEmployee NamePosition No.Employee 900#Exempt ?Non-Exempt ?Job TitleDepartment InformationDepartment InformationSupervisor NameSupervisor 900#DepartmentRequest DetailsRequest DetailsI am at high risk for COVID-19 due to the following reason(s):I am age 65 or olderI have an underlying medical conditions: (attach report from Medical Doctor)Chronic lung disease or moderate to severe asthmaSerious heart condition(s)Immunocompromised Severe obesity (body mass index [BMI] of 40 or higher)DiabetesChronic kidney disease undergoing dialysisLiver disease342900293370Proposed Schedule Details00Proposed Schedule Details2092960104140Other (please explain)Proposed Schedule: Week 1Proposed Schedule: Week 2Proposed Schedule: Week 3Proposed Schedule: Week 4DaysDateTotal # of HoursDaysDateTotal # of HoursDaysDateTotal # of HoursDaysDateTotal # of HoursSunSunSunSunMonMonMonMonTuesTuesTuesTuesWedWedWedWedThursThursThursThursFriFriFriFriSatSatSatSat*If additional columns are need for Week 5, please complete another form and change the proposed scheduled week to indicate Week 54562475342900001095375356870Week BeginningWeek EndingA Work from Home Request must be submitted every month. Department head may require the form to be submitted on a weekly or bi-weekly basis.379095-155257500379095-132397500379095-1095375003922395-1552575003922395-1323975003922395-109537500The following factors have been taken into consideration with this proposal. The following pertains:ConsiderationsResultConsiderationsResultThis department will continue to be open from the hours of 7 a.m.-Noon and 12:30-5:30 p.m., Monday through Thursday.This employee’s “work from home” arrangement will not adversely affect the operations of the department.The position identified in this request is conducive to a “work from home” arrangement.A plan has been developed to monitor the performance of the employee making this “work from home request”. (Attach copy of plan)The employee has been notified that the department may discontinue, temporarily suspend, or alter the “work from home” arrangement if business needs change, service is impaired, or there is a change in law or university policy.The quantity, quality, and timeliness of the employee's work are anticipated to be maintained or enhanced.The “work from home” arrangement will cause need for overtime or additional staff.YesNo5865495-317500006706870-317500005865495254000067068702540000YesNo5865495254000067068702540000YesNo5865495260350067068702603500YesNo5873115260350067144902603500YesNo5873115254000067144902540000YesNo5873115254000067144902540000YesNo Signatures159385023685500525145023685500Employee signatureDate159385021971000525145021971000Supervisor signatureDate159385021971000525145021971000Department head signatureDate159385021971000525145021971000Vice President signatureDateHuman Resources to provide a copy to the Office of the President (Box A-1). ................
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