- To serve as the primary document to record an employee's daily work schedule and assigned tasks.
- To document changes to the employee's work schedule, assigned tasks or both.
When to Prepare
The employer completes this form on the hire date and any time the employer makes one or more changes to either the employee's work schedule or assigned tasks. This form is not required when the employer provides a program-specific form or other documentation.
Number of Copies
Original and two copies for an employee’s initial work schedule and for any change to the employee's schedule. Original and one copy for changes to assigned tasks only.
The employer keeps the original form and gives one copy to the employee and one copy to the Financial Management Services Agency (FMSA) for the employee's initial schedule and for any change to the schedule. For any change to the assigned tasks, the employer keeps the original form and gives a copy to the employee; if a change does not affect the employee's work schedule, the employer does not send a copy to the FMSA.
The employer and the FMSA must keep this form for five years after termination of the employee or until the resolution of all outstanding litigation, claims and audits.
Employee Name — Enter the name of the employee.
Purpose of Form
Initial/Change — Check only one box to indicate whether this form is for the initial (first) schedule and tasks, or if the form reflects a change to the employee's schedule, tasks or both.
Tasks/Schedule — Check one or both boxes to indicate whether this form is documenting the work schedule, the assigned tasks or both.
Effective Date — Enter the date that the schedule and/or list of tasks is effective.
The form provides space for the employer to document three schedules. An example of using two schedules may apply to an individual who attends school. The first schedule may be for School while the second schedule may be for Summer Months and Holidays. For each Time In and Time Out entry, use AM and PM to distinguish the time of day, or record in military time.
Schedule I — The employer enters a description of the schedule if there is more than one schedule.
Time In — Enter the time the employee is scheduled to start working. Space is available for six Time In entries per day. The first line may be used for the morning work schedule; the second line may be used for the afternoon or evening work schedule.
Time Out — Enter the time the employee is scheduled to stop working. Space is available for six Time Out entries per day.
Total Hours — Enter the total daily hours the employee is scheduled to work. Space is available for two Total Hours entries per day.
Weekly Total Hours — Enter the total number of hours the employee is scheduled to work in the week for Schedule I.
Schedule II — If there is more than one schedule, the employer completes the second schedule as done for Schedule I.
The form provides a section for listing the tasks for Schedule I and for Schedule II (if needed). The tasks may be different depending on the schedule.
Schedule I – Tasks/Schedule II – Tasks — Enter the tasks the employee will be delivering during the work hours. If needed, continue entering tasks on an additional sheet of paper attached to this form.
Acknowledgement of Work Schedule and Assigned Tasks
The employee and the employer each sign and date this form to acknowledge the employee's work schedule(s) and the assigned tasks for each schedule.