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NEW PATIENTS - GETTING STARTED
Patient Portal

4-Day Work Week Interest Form

4-Day Work Week Interest Form

Location(Required)

Employee Benefits Eligibility

| FULL-TIME: Eligible for medical, dental, vision and FSA benefits, PTO accrual, CUPTO, and holiday pay. (Number of visits seen ST = 50, OT/PT = 30, LPC = 25 visits) | PART-TIME PLUS: PTO accrual and holiday pay. (Number of visits seen ST = 45, OT/PT = 25, LPC = 25) | PART-TIME: Not eligible for any employer sponsored benefits. |
If transitioning to a 4-day schedule, how would you prefer your employment status to be classified?(Required)

I understand that eligibility for medical, dental, vision, and FSA benefits is contingent upon meeting minimum hourly requirements, and that transitioning to 4 days may impact or terminate my eligibility.(Required)

Do you need to maintain eligibility for employer-sponsored benefits? (Medical, Dental, Vision, FSA, etc.)(Required)

To maintain productivity and coverage, 4-day schedules may require extended daily hours. Please select all schedules you would be willing to work.(Required)

Which hours would you prefer to avail yourself:(Required)

Transitioning to a 4-day work week no longer allows for any late start days.(Required)

I understand that transitioning to a 4-day work week may impact my compensation and/or other incentives. I further understand that by changing my schedule, I may have reduced access to higher-demand “prime time” appointment slots, which could affect my overall income.(Required)

Acknowledgment that you will no longer be eligible for (CUPTO)(Required)

I understand that the 4 days will likely not be consecutive, depending on department's scheduling needs.(Required)

Please list your top three days in order

Transition to a 4-day work week cannot be implemented until appropriate coverage has been secured for your currently scheduled patients. Depending on departmental staffing and patient demand, this process may take time and is not guaranteed within a specific timeframe.(Required)

I understand that submitting this form adds me to the 4-day work week interest list only, and does not guarantee approval or implementation of a schedule change. I understand this is a waiting list process, and requests will be reviewed and processed based on departmental needs, operational capacity, and seniority. I also understand that completion and submission of this form will be considered in prioritization.(Required)

Please any additional comments you would like the manager to review below then submit this form.