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U.S. DOD Form dod-va-3497 EMPLOYEE REQUEST FOR CHANGE TO PART-TIME EMPLOYMENT PRIVACY ACT STATEMENT The information requested on this form is solicited under authority of 5 U.S.C. REASON FOR DISAPPROVAL 10. PROPOSED EFFECTIVE DATE 11. SIGNATURE OF SECOND-LINE SUPERVISOR OR APPROVING OFFICIAL Month day year VA FORM DEC 1990 5-3497 EXISTING STOCK OF VA FORM 5-3497 NOV 1983 WILL BE USED. 301 and is considered relevant and necessary to process your request for change to part-time employment. Though your response is voluntary failure to provide necessary information may delay processing* Furnished information may be disclosed outside the Department of Veterans Affairs only as permitted by law. INSTRUCTIONS After completion of Items 1-7 by the employee this form should be given to the immediate supervisor. It is the responsibility of the immediate supervisor to explain the effects of such a change on the employee s rights and benefits. The supervisor will then evaluate the request in terms of employment ceilings workloads equipment requirements etc* and prepare a written recommendation on to the second-line supervisor or approving official* If approved one copy of this form is to be attached to VA Form 5-4652 Request for Personnel Action and forwarded to the personnel office. If not approved one copy of this form is to be forwarded to the personnel office so that the request can be retained for consideration when part-time vacancies occur. NOTE Additional information on part-time employment may be found in MP-5 Part I Chapter 340 or through your personnel office. 1. NAME OF EMPLOYEE Last first middle 3. SERIES AND GRADE 2. TITLE OF PRESENT POSITION 4. DEPARTMENT/STAFF OFFICE SERVICE AND DIVISION TO WHICH ASSIGNED 5. SCHEDULE List specific hours SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY A. PRESENT WORK WEEK B. REQUESTED WORK WEEK 6. REASON FOR REQUESTING CHANGE TO PART-TIME EMPLOYMENT e*g* family responsibilities school etc* 7. EMPLOYEE S STATEMENT OF UNDERSTANDING I have reviewed and understand the information on this form pertaining to the effects that converting to part-time will have on my rights and benefits. A. SIGNATURE OF EMPLOYEE B. DATE SIGNED Month day year 8. DECISION ON REQUEST To be completed by second-line supervisor or approving official CHECK APPROPRIATE BOX APPROVED If checked also complete Items 10 11 and 12 DISAPPROVED If checked also complete Items 9 11 and 12 9. 301 and is considered relevant and necessary to process your request for change to part-time employment. Though your response is voluntary failure to provide necessary information may delay processing* Furnished information may be disclosed outside the Department of Veterans Affairs only as permitted by law. Though your response is voluntary failure to provide necessary information may delay processing* Furnished information may be disclosed outside the Department of Veterans Affairs only as permitted by law. INSTRUCTIONS After completion of Items 1-7 by the employee this form should be given to the immediate supervisor..

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