Page 211 - Personnel Policy and Procedures Manual

Form RM-WC-RTDA
REQUEST FOR TEMPORARY DUTY ASSISTANCE
(Temporary duty to last for up to 12 weeks with one additional 12 week extension if necessary)

Department Name - Today’s Date -

Contact Person - Phone # -

Position to be filled -

Duration of Position -
Start Date - End Date -

Location of Position -

Work Days - Work Times -
8 hours daily/5 days per week Start Time - a.m./p.m.
10 hours daily/4 days per week End Time - a.m./p.m.
Other (please specify) -

Brief Description of duties -

Additional Comments -

Temporary Duty Employee Assigned -

Date Employee Assigned -

Additional Comments -

THIS RECEIPT SHALL BE READ AND SIGNED BY THE EMPLOYEE. RISK MANAGEMENT SHALL
COUNTERSIGN THE RECEIPT AND PLACE IT IN THE EMPLOYEE’S WORKER’S COMPENSATION FILE.

Employee’s Signature - Date -

Risk Management - Date -

cc - Employee’s Primary Department

All Rights Reserved – As approved by the Commission on 05-07-2019 210 | P a g e