MS/HS Request for In-Person Work by Individual Employee

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Pursuant to the October 14, 2020 Michigan Occupational Safety and Health Administration (MIOSHA)
Emergency Rules, in-person work for employees is prohibited “to the extent that their work activities can feasibly
be completed remotely.” If an employee insists on performing work in-person at the school, the employee must
complete this request form and submit it to the Building Administrator who should review the form and determine whether some or all aspects of the employee’s work cannot feasibly be completed remotely.

Employee Full Name *

Job Title *

Building *

Middle/High School

Date *

YYYY

Time In *

Time

Reason for entrance *

The Employee is experiencing issues with internet, connectivity, which is necessary to perform work

The Employee is conducting a special project that requires classroom resources (e.g., science project).

The Employee is obtaining, printing, or making copies of classroom materials.

Other:

Reason for entrance: IF OTHER, please specify (put N/A if reason was specified in previous question). *

Please type your initials below *

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