Full Name Contact/Cell # Personal Email Address Agency Official Job Title What Was the Request That Was Denied? * Denied Less than 50% Telework Denied 50% Telework Denied 60% Telework Denied 70% Telework Denied 80% Telework Denied 90% Telework Denied 100% Telework Teleworking History In This Job Title * I was able to Telework 50% I was able to Telework >50% I was Teleworking 100% About What Date Did You Submit Your Telework Request Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 About What Date Did The Agency Give You The Denial Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Was The Agency Response In Writing Yes No Type of Agency Response... * - Select -Total DenialPartial DenialDenied Then Modified For An Approval Are You Making a Claim of "COVID-fragile" circumstances? Yes No Are You Considered a Field Employee? Yes No What about the Denial Are You Seeking to Appeal...please explain briefly Leave this field blank
