Out-of-State Work Request/Approval Form | Office of Human Resources

What type of request is this? *

Initial request

Extension of an existing request

Does your request require SMD Faculty Affairs review? *

Yes

Requester information

Department contact/Requestor *

Requestor work email address *

Employee/Candidate name *

First

Last

Employee ID/Applicant number (if known)

Division /Department number *

Department name *

Job code *

Job Title *

FAO *

The department will be charged quarterly for any employee working out of state. Additional fees may apply.

Is there an offer pending for this employee? *

Yes

Employment status *

Full-time

Part-time

TAR*

*When the work location is not required for the work to be performed students and TAR staff should be paid through a payrolling agency in that work location. Email HROutofStateRequest@rochester.edu for assistance.

Payroll status *

Exempt (salaried)

Non-Exempt (hourly-paid)

Proposed pay rate/salary *

Start date at out-of-state work location *

Please use the format MM/DD/YYY.

Expected end date of assignment at this work location (if applicable)

*If request is not for a UR designated location, approval to work out of state may be limited to a maximum of one year and will require a new request form be submitted at least 4-6 weeks prior to the end date to allow time to re-evaluate employment regulations for that state to ensure we are able to remain compliant. Please use the format MM/DD/YYY.

Where work is to be performed

State *

County *

City *

Country (if outside USA) *

Percent of time work will occur in NY *

Percent of time work will occur in other State/Country (approx. if unknown) *

(approx. if unknown)

Will the employee/candidate be a resident of the out-of-state location requested? *

Yes

Business need/justification for out-of-state request

Please explain the Business Need for why the work must be performed in this out-of-state location: Provide separate sheet if space below is insufficient.

Please attach required approval (i.e. an email with the employee's name, job title, and desired work location) from the supervising senior administrator (i.e., Dean, Vice-Provost or Vice-President, or Director) and the divisional finance approver. *

Max. file size: 20 MB.