Human resources
Remote work request template (US)
A general template under US law. Laws differ from state to state, so check it against your state's law or with a lawyer licensed there. We are not a law firm and do not give legal advice.
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Preview — US standard
Remote Work Request
To: Manager Name, Manager Title
From: Employee Name, Job Title, Department
Date: Request Date
I am requesting to work remotely as follows:
| Item | Details |
| --- | --- |
| Arrangement | Fully Remote or Hybrid |
| Days or schedule | Remote Days and Hours |
| Start date | Proposed Start Date |
| Trial period | Trial Period, such as 90 days |
| Remote work location | City and State of Remote Location |
Reason
Reason for the Request
If this request relates to a disability or a pregnancy-related limitation, please treat it as a request for reasonable accommodation, and I will provide any information the process requires.
How the Work Will Get Done
• Availability: I will be reachable by Communication Tools during Core Hours and Time Zone.
• Meetings: I will attend Meeting Plan and come to the office for In-Office Needs.
• Equipment: Equipment Needed or Already Available.
• Security: I will follow the Company's data security policies, use a secure network, and protect confidential information.
• Results: Progress can be measured by Measures of Performance.
I understand the working location may affect tax withholding and other employment laws, and I will tell the Company before changing the location.
I am happy to discuss this and to review the arrangement after the trial period.
Employee Signature
Employee Printed Name
For Company Use
Decision: Approved, Approved with Changes or Not Approved
Conditions: Conditions or None
Approved by: Approver Name and Signature Date: Decision Date