Telecommuting Request

Telecommuting Request

Employee / Title
Supervisor / Department
Employee’s home address
/ Employee’s home phone
Commuting time (one way)
Commuting distance (one way)

1. What are your current job duties?

1. Why are your job duties well-suited for telecommuting? How would the quality and efficiency of your work be improved by telecommuting?

1. What job tasks do you propose to do at home?

1. What job tasks would you be unable to perform from home?

1. Describe the space in your home that you intend to use as a work area.

1. What equipment do you need to telecommute that you do not already have?

1. What distractions or obligations might make it difficult to work at home? How do you plan to resolve these potential problems?

1. Do you have any other questions or concerns regarding telecommuting?

Proposed start date: _____ / _____ / _____

Proposed schedule:

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
At
home
In
office

I understand that this request does not guarantee that I will receive approval to telecommute. I also understand that I will not be permitted to telecommute until I have signed a Telecommuting Agreement, and that Agreement has been approved and signed by my supervisor [add if appropriate: and an authorized representative of the company]. The terms and conditions of an approved telecommuting arrangement, including the hours to be worked, will be solely governed by the Telecommuting Agreement, and not by this request or any verbal agreements. If changes are to be made to the Agreement, they must be in writing with all necessary signatures. I have read and understand [Company’s] Telecommuting Health and Safety Policy. If my telecommuting request is approved, I will abide by the terms of that policy.

Employee's signature Date _____ / _____ / _____

TO BE COMPLETED BY SUPERVISOR

1. Are all of the employee’s job duties well-suited to telecommuting?  Yes  No
2. Do you expect to be able to communicate effectively with the employee at the employee’s home, if necessary?  Yes  No
3. Are the employee’s knowledge, skills, abilities and work habits conducive to telecommuting?  Yes  No
4. Are any anticipated costs to the company of setting up and maintaining the employee’s home office reasonable?  Yes  No
5. Will the proposed home office enable the employee to adequately perform his or her job duties?  Yes  No
6. Will the proposed telecommuting arrangement result in a savings to, or other positive impact on, the company?  Yes  No

If you answered “no” to any of the above questions, please explain below. You may also address the employee’s concerns, express your own concerns, or add any other comments or recommendations regarding the proposed telecommuting arrangement.

I  approve  do not approve this telecommuting request.

(If approved, please meet with the employee and draft a Telecommuting Agreement, then submit the Agreement and this Request to Human Resources for final approval. If not approved, please explain the reason below and submit a copy of this Request to Human Resources to be placed in the employee’s file. If you would consider approving the employee’s request if appropriately modified, you may meet with the employee to discuss modifying and resubmitting the request.)

Reason for not approving request:

Supervisor's signature Date _____ / _____ / _____

Form 9098-1-1 Telecommuting Request Page 3 of 3

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