MS/HS Request for In-Person Work by Individual Employee
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.
* Required
Employee Full Name
*
Your answer
Job Title
*
Your answer
Building
*
Middle/High School
Date
*
MM
/
DD
/
YYYY
Time In
*
Time
:
AM
PM
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).
*
Your answer
Please type your initials below
*
Your answer
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