NRHEG Short-term COVID-Related Telework Request

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Use this form to request a short-term (14 days or fewer) telework accommodation if you are unable to be in the building due to a COVID-Related reason, but you are well enough to work your regular hours.

Email *

Employee First Name *

Employee Last Name *

Requested Telework Start Date *

YYYY

Requested Telework End Date

YYYY

Employee Position

Identify and describe the reason for the telework request.

Which of the following pertains to the reason for your request? *

(1) You are subject to a Federal, State, or local quarantine or isolation order related to COVID-19

(2) You have been advised by a health care provider to self-quarantine related to COVID-19

(3) You are experiencing COVID-19 symptoms and are seeking a medical diagnosis

(4) You are caring for an individual subject to an order described in (1) or self-quarantine as described in (2)

Required

Include any additional information you would like to share in this section.

By providing your typed name below, you are confirming that all information in this form is true and accurate.

Employee Signature *

Date Signed *

YYYY

Submit

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