Form Ct-Hr-7c - Request For Schedule Change Under The Voluntary Schedule Reduction Program (Vsrp) - Connecticut

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State of Connecticut Department of Administrative Services
Request for Schedule Change under the Voluntary Schedule Reduction Program (VSRP)
(Governors’ Request of March 2009 until further notice)
Form #: CT-HR-7c
REVISION DATE: 8/2009
In order to be eligible to participate in the VSRP, employees must: (1) meet the definition of ‘permanent employee’ as
provided by C.G.S. §5-196, (2) ensure the hours worked in any given week equals or exceeds the minimum number of
hours required for eligibility for health insurance benefits and (3) receive approval from the Agency Head/Designee prior
to beginning leave under the VSRP. Employees are advised that leave taken under the VSRP will not be counted toward
completion of the promotional working test period and the expiration date of such working test period will be extended by
the equivalent number of days. The VSRP is not subject to the grievance or arbitration procedure. Leave taken under
the VSRP shall not be granted if the effect would be to incur overtime costs.
Part I: To be completed by the employee requesting a schedule reduction under the VSRP
I am a permanent State employee and request to take unpaid voluntary leave pursuant to CGS §5-248c.
NAME: _______________________________________ AGENCY: __________________________________________________
JOB TITLE: ___________________________________ DIVISION/OFFICE:__________________________________________
BARGAINING UNIT: ___________________________ WORK LOCATION: _________________________________________
REQUEST IS MADE FOR THE PERIOD COVERING
1
: ___________________________ TO____________________________
Schedule Reduction Request: Select ONE option below and describe in detail how you wish to use the Program.
OPTION A
I am requesting to take sporadic individual full days off or partial days off without pay. (The days include days I am
scheduled to work and do not include holidays.)
The actual day(s), hours and date(s) I am requesting off under the VSRP during this time period are as follows:
(Examples: Full day = Wed., 7/8/2009; Partial day = Wed. 7/8/2009 - 1:00 pm - 4:30 pm)
________________________
________________________
________________________
_________________________
________________________
________________________
_________________________
________________________
________________________
_________________________
________________________
________________________
OPTION B
I am requesting a reduction in scheduled weekly hours from _____ to _____
C
H
W
:
R
H
VSRP:
URRENT
OURS OF
ORK
EQUESTED
OURS UNDER
M
– F
: _____ T
: _____
M
P
: _____
M
–
F
: _____ T
: _____
M
P
: _____
ONDAY
R
O
EAL
ERIOD
ONDAY
R
O
EAL
ERIOD
T
– F
: _____ T
: _____
M
P
: _____
T
–
F
: _____ T
: _____
M
P
: _____
UESDAY
R
O
EAL
ERIOD
UESDAY
R
O
EAL
ERIOD
W
. – F
: _____ T
: _____
M
P
: _____
W
. –
F
: _____ T
: _____
M
P
: _____
EDNES
R
O
EAL
ERIOD
EDNES
R
O
EAL
ERIOD
T
– F
: _____ TO: _____
M
P
: _____
T
–
F
: _____ TO: _____
M
P
: _____
HURSDAY
R
EAL
ERIOD
HURSDAY
R
EAL
ERIOD
F
–
F
: _____ T
: _____
M
P
: _____
F
–
F
: _____ T
: _____
M
P
: _____
RIDAY
R
O
EAL
ERIOD
RIDAY
R
O
EAL
ERIOD
S
– F
: _____ T
: _____
M
P
: _____
S
–
F
: _____ T
: _____
M
P
: _____
ATURDAY
R
O
EAL
ERIOD
ATURDAY
R
O
EAL
ERIOD
S
–
F
: _____ T
: _____
M
P
: _____
S
–
F
: _____ T
: _____
M
P
: _____
UNDAY
R
O
EAL
ERIOD
UNDAY
R
O
EAL
ERIOD
Special Notes: (These apply to both Option A and Option B)
1.) This request can cover a maximum period of time of three (3) months.
2.) Leave taken under the VSRP must be in increments of at least one hour.
3.) Unpaid meal periods are required when an employee works more than six hours per day. Meal periods must be
scheduled mid-shift and must be at least 30 minutes in duration.
I understand the VSRP is optional on my part and on the part of my agency and that my agency’s appointing
authority/designee must approve my request before I may participate in the VSRP. I also understand this arrangement
may be modified, amended or terminated at any time by written notification from the agency head, or designee, with or
without cause.
_______________________________
_________________
Employee’s Signature
Date

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