Work Schedule/Shift Change Request
Submit completed form to your Human Resources (HR) Office. Form must be received by the HR Office prior to schedule
effective date.
Workweek: A fixed block of seven consecutive 24-hour periods.
Work Schedule: Description of the days and hours within the workweek an employee is scheduled to work.
Name (Last, First, Middle Initial) Personnel Number
Enter text. Enter text.
Class Title Position Number
Enter text. Enter text.
New Position Number (If Changed) Is Position Overtime Eligible?
Enter text. Yes No
Effective Date (First day of Workweek) Work Location or Unit
Enter a date. Enter text.
Select Work Schedule from one of the drop down boxes below OR select Other.
Other: Enter Work Schedule.
Workweek 1 Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Daily Shift Start Time Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Daily Shift End Time Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Length of Lunch Break Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Workweek 2 (If Sunday Monday Tuesday Wednesday Thursday Friday Saturday
applicable)
Daily Shift Start Time Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Daily Shift End Time Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Length of Lunch Break Enter text. Enter text. Enter text. Enter text. Enter text. Enter text. Enter text.
Reason for Work Schedule/Shift Change and Comments.
Enter text.
Check All That Apply: Supervisor’s Notice to Employee (Refer to WAC 357-28-252) For Training Purposes
Employee’s Request To Supervisor Mutually Agreed Change Permanent Change Temporary Change
Date Employee Signature
Enter a date. Enter text.
Date Supervisor/Manager Signature
Enter a date. Enter text.
For Human Resources Office Use
Employee’s Work Week Copies Distributed To
Enter text. HR Office (original) Attendance Keeper Employee Supervisor
Date HR Designee’s Signature
Enter a date. Enter text.
OFM 12-008 (1/15/14) Work Schedule/Shift Change Request