Appendix 1: SAMPLE Telecommuting

application form and agreement

This form and agreement was created to facilitate and document a telecommuting arrangement for WA Health employees and managers.

Requests for telecommuting arrangements are governed by the WA Health Telecommuting Policy which is available through HealthPoint.

Employees and managers should read the WA Health Telecommuting Policy prior to applying for or determining a telecommuting application.

  1. Telecommuting Arrangement Application Form

PLEASE COMPLETE ALL SECTIONS OF THE APPLICATION FORM

Name (please use full name):
HE Number: / H / E
Employee Number:
Position Title:
Health Service/Department:

Please detail your proposed telecommuting arrangement

(Note: see section 4 of the Policy for further information)

Proposed telecommuting arrangement start date:______

Proposed telecommuting arrangement end date :______

(Note: telecommuting arrangements to be reviewed every six months or earlier if the circumstances change for the employee or employer)

When this request is assessed, I would like the following information/circumstances to be taken into consideration:

I acknowledge the following:

  • I understand telecommuting arrangements need to be reviewed every six months or earlier if the circumstances change for either the employee or employer.
  • I understand I am responsible for maintaining the confidentiality and appropriate storage of WA Health documents and records (paper and electronic) in accordance with applicable WA Health Policies and Procedures during the term of the telecommuting arrangement.
  • I agree to comply with applicable Health Service Occupational Safety and Health and HIN technology and software requirements

I agree that if approved, my manager has the right to request for me to change the working arrangement, even if temporarily, to meet special conditions or unforeseen circumstances.

Proposed by (employee name) ______

Signature ______

Date ______

  1. Telecommuting Arrangement Application – Manager’s Response

Notes for Managers

  • Managers should read the WA Health Telecommuting Policy prior to responding a telecommuting application.
  • Managers should contact Health Service Human Resources/Workforce for advice and assistance about telecommuting arrangements and/or employee requests.
  • Prior to a telecommuting arrangement being approved or denied, managers must consult with the Delegated Authority.

2.1Manager Response – Telecommuting Arrangement Request Approved

This request has been approved following consultation with the employee:  (Tick)

Start Date:Review Date:

(Note: Telecommuting arrangements need to be reviewed every six months or earlier if the circumstances change for either the employee or employer)

When and how will co-workers be advised of this change?

This request complies with:

  • applicable Health Service OSH requirements ensuring the employee  (Tick)

is able to safely carry out their work in their home/remote site

  • applicable Health Information Network technical and software  (Tick)

requirements.

This request will be documented as an agreement (see sample agreement below)  (Tick)

Line Manager confirmation

(Line Manager to confirm the above telecommuting arrangement is suitable for the workplace and complies with the above requirements)

Line Manager Signature: ______

Date: ______

Delegated Authority’s name ______

Signature ______

Date ______

(refer to the Uniform Human Resource delegations for WA Health Entities – OD 0515/14 for further information)

2.2Manager Response – Telecommuting Arrangement Request Denied

This request has been denied following consultation with the employee:  (Tick)

Reasons for denying this request

(Note: a telecommuting arrangement may be refused on reasonable business grounds. This may include, but is not limited to:
  • impact on client service/patient care
  • unreasonable implementation costs to the organisation
  • unreasonable change to the working arrangements of other employees
  • lack of adequate replacement staff
  • loss of efficiency and/or productivity
  • non-compliance with Health Service OSH and/or Health Information Network requirements.

Outcome discussed with employee on: (Date)

Copy given to employee on:(Date)

Delegated Authority’s Name______

Signature______

Date ______

(Please refer to the Uniform Human Resource delegations for WA Health Entities – OD 0515/14 for further information)

  1. Telecommuting Arrangement Agreement Template

Telecommuting Arrangement Agreement

Between

______

Name of Employee

______

Position Title and Work Unit

and

______

Delegated Authority’s name

______

Name of Organisation

The purpose of this agreement is to detail the telecommuting arrangement agreed between the above parties. The terms of this agreement are based on the WA Health Telecommuting Policy (copy attached).

Agreed telecommuting arrangements are as follows:

Commencement Date: ______Review Date: ______

Details:

(Note: please outline the employee’s role and responsibilities under the arrangement, including communication and supervision requirements if applicable).

Additional Comments:

We have read and understand the arrangements detailed in this agreement and the

WA Health Telecommuting Policy. We understand that applicable legislation and WA Health policies continue to apply to the telecommuting employee as they would if the employee was working at the employer’s workplace.

We confirm that this telecommuting arrangement:

  • does not compromise service delivery which we understand takes precedence
  • complies with applicable Health Service Occupational Safety and Health requirements and Health Information Network information technology and software requirements.

We acknowledge that this agreement must be reviewed on at least a six monthly basis (or earlier if the circumstances change for either the employee or employer) ensuring consideration is given to the operational effectiveness of the agreement including impacts on the organisation, the work unit and the individual employee.

We confirm the employee or employer may withdraw from this agreement upon providing [insert agreed notice period] written notice to the other party.

Employee’s Signature: ______Date:______

Delegated Authority’s Signature: ______Date:______

Telecommuting Arrangement Agreement Extension (if applicable)
(Note this section is not to be used to amend or include new agreement terms. Please prepare a new telecommuting arrangement agreement in these circumstances).
We have reviewed the above telecommuting arrangement agreement and agree to extend this agreement. We confirm this extension does not amend the above agreement terms or include new agreement terms, subject to the extension commencement and review date detailed below.
Extension commencement date: ______
Review date (maximum 6 months from extension commencement date): ______
Employee’s Signature: ______Date:______
Delegated Authority’s Signature: ______Date:______

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This document can be made available in alternative formats
on request for a person with a disability.

© Department of Health 2015

Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia.