Adjustable Work Schedule Change Request

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MINNESOTA STATE UNIVERSITY, MANKATO
ADJUSTABLE WORK SCHEDULE CHANGE REQUEST
1. Name: ___________________________________
Job Title: ___________________________
2. Department: ______________________________
Building: ___________________________
3. Current Schedule:
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□
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Days:
Monday – Friday
Tuesday – Saturday
Sunday - Thursday
Hours:
Start time ___________ a.m. / p.m.
End time ____________ a.m. / p.m.
4. I request my schedule to be changed to:
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□
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Days:
Monday – Friday
Tuesday – Saturday
Sunday - Thursday
Hours:
Start time ___________ a.m. / p.m.
End time ____________ a.m. / p.m.
5. Effective Date: ______________________
End Date: ___________________________
6. Reason for request:
7. Anticipated benefit to employee, office or department, if approved:
8. Employee Signature: ________________________________
Date: _____________________
Supervisor’s Approval / Denial Signature:
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Approved: _______________________________________
Date: _____________________
□
Denied: _________________________________________
Date: _____________________
Reason for denial: _____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Approved: __________________________________________
Date: _____________________

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