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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 7, Chapter 6:  Manual Exhibit 7-6-2-A

Sample Format -
Request to Participate in the FWAP


TO: Approving Official
THRU:  (Name of Immediate Supervisor)

FROM: Employee

SUBJECT: Request to Participate in the FWAP

I wish to participate in the FWAP for the following reason(s):

Include all information necessary to evaluate the request, e.g., any relevant physical disability or illness, arrangements that will be made for the care of young children or other dependents, etc.  Indicate the expected duration of the arrangements and the number of days or hours per week you wish to work away from your official work station.  Attach any medical documentation or other information you wish to have considered.  Specify where you would like to work offsite, i.e., at your home or at a telecommuting center.  Indicate also any equipment you think would be necessary at the alternate worksite for you to perform your job.

Signature:__________________________ Date:____________________

Position Title:_______________________________________________

Grade Series, and Pay Plan:___________________________________

Immediate Supervisor:  Concur_____ Non-Concur_____

Reason(s) for Determination:

Signature:__________________________ Date:____________________

Approving Official:  Concur_____ Non-Concur_____

Reason(s) for Determination:

Signature:__________________________ Date:____________________


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