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WorkLife Connections
Business Operations
rd
3 Floor, Lakeshore Center
(906) 487-2437
Flexible Work Option (FWO) Agreement
Part I – FWO Details
To be completed by employee.
Employee Name:
Title:
Department:
Email:
Phone#:
Official Work Location:
Employee Type:
 Non-exempt (hourly)
 Exempt
Supervisor’s Name:
Supervisor’s Email:
Phone#:
This is a:  New request
 Renewal
Proposed FWO Start Date:
 Modification of current arrangement
Proposed FWO end date of arrangement:
Check type of Flexible Work requested & Provide Details:
(Options continue on next page.)

Flextime – arrangement that allows a full-time exempt or non-exempt staff member to, with his or her
supervisor, agree on starting and ending times of the work day.
 Fixed starting and ending times
Proposed schedule
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Wednesday
Thursday
Friday
Saturday
 Fixed varied starting and ending times
Sunday
Monday
Tuesday
 Adjusted meal period
Start Time
Length of Adjusted Meal Period
End Time
Hours Worked
Michigan Tech WorkLife Connections Office – x72437 – Business Operations– 3rd Floor,
Lakeshore Center Form Last Updated 26 February 2016

Compressed Workweek – arrangement that enables a full-time employee to complete 40 hours of
work in fewer than five full days
 10-hour work day for 4 days with one day off per week
(Indicate regular day off ____________)
 9-hour work day for 4 days with ½ day off per week
(Indicate regular half-day off ___________)
 Other – Please describe:

Flexplace/Telecommuting* – allows for a portion of the job to be performed off-site, on a regular,
recurring basis, usually at the worker’s home.
* Details must be provided on the Flexplace/Telework Agreement (required for approval of the
arrangement) form available at http://www.admin.mtu.edu/hro/fwo.
Part II – Proposed Work Plan
To be completed by employee.
Provide a written overview of the work arrangement you are proposing (attach additional sheets if
necessary). Be sure to include the following information:
Proposed Work Plan (how you will provide the same or improved service to your internal and external customers,
co-workers and other university departments):
Advantage(s) to the department:
Michigan Tech WorkLife Connections Office – x72437 – Business Operations– 3rd Floor,
Lakeshore Center Form Last Updated 26 February 2016
Plan for communication/cooperation with others in the office:
Plan for accessibility and responsiveness to work needs:
Plan for continuity of work:
Michigan Tech WorkLife Connections Office – x72437 – Business Operations– 3rd Floor,
Lakeshore Center Form Last Updated 26 February 2016
Plan for back-up (if needed):
Any obstacles you see that may result in the denial of your request, and your proposal to resolve/address them:
By signing this agreement, I state that I have read and understand the Flexible Work Options
guidelines and agree to the terms and conditions set forth by this agreement. I believe that my
work can be completed within the above schedule with no loss of customer service or disruption
to others in my department, the University or external customers. I understand that it is my
responsibility to make my flexible work arrangement a success. A supervisor or staff member
may terminate or modify the arrangement at any time within the guidelines of contractual
obligations (if applicable). I also understand that I must submit a new Flexible Work Options
form anytime I wish to make a continuing change to my schedule, including returning back to
regular work hours.
If I am an hourly employee and will be working a compressed workweek, I understand that I will
not be paid overtime (time and one-half) for working more than 8 hours per day. Overtime
requires supervisor approval.
Employee signature
Date
Michigan Tech WorkLife Connections Office – x72437 – Business Operations– 3
Floor, Lakeshore Center Form Last Updated 26 February 2016
rd
Part III – Supervisor Response
To be completed by supervisor


Flexible work arrangement approved
Flexible work arrangement approved with modifications
Describe modifications:
This arrangement will be reviewed at least annually by the Supervisor and Employee.
Date for next review:
Supervisor signature
Date
NOTE: If you approve this FWO proposal for hourly staff, please review guidelines for hourly
employees regarding requirements for overtime pay.
Please send completed and signed form to:
WorkLife Connections
3rd Floor, Lakeshore Center
worklife@mtu.edu
Questions? Need more info?
Contact: (906) 487-2437
Michigan Tech WorkLife Connections Office – x72437 – Business Operations– 3
Floor, Lakeshore Center Form Last Updated 26 February 2016
rd