Part 1--General Information (Please
type or print clearly)
Employee Name:
Component:
Location:
Phone:
Immediate Supervisor's Name:
Part 2--DOJ Telecommuting Agreement
The following constitutes an agreement on the terms and conditions of
the telecommuting arrangement between:
Component/Division:
Employee:
1. The employee volunteers to telecommute and to adhere to the applicable
guidelines and policies. The agency concurs with employee participation
and agrees to adhere to the applicable guidelines and policies.
2. The employee agrees to participate for an initial period beginning: and ending: . This agreement may be extended beyond the initial period if agreeable
to the agency and to the employee. In such a case, the terms of this
agreement should be reviewed and updated as necessary.
3. The employee's official tour of duty will be from:
to:
on the following days:
4. The employee will be working at the alternate worksite from:
to:
on the following days:
5. Employee's official duty station is:
The alternate worksite is located at:
Describe in detail the designated work area at the alternate worksite:
All pay, special salary rates, leave and travel entitlements will be
based on the employee's official duty station.
6. The employee's timekeeper will have a copy of the employee's telecommuting
schedule. The employee's time and attendance will be recorded as performing
official duties at the official duty station.
7. The employee must obtain supervisory approval before taking leave
in accordance with established office procedures. By signing this
form, the employee agrees to follow established procedures for requesting and
obtaining approval of leave.
8. The employee will continue to work in pay status while working
at alternate worksite. If the employee works overtime that has been ordered
and approved in advance, he/she will be compensated in accordance with
applicable law and regulations. The employee understands that the
supervisor will not accept the results of unapproved overtime work and
will act vigorously to discourage it. By signing this form, employee
agrees that failing to obtain proper approval for overtime work may result
in her/his removal from telecommuting or other appropriate action.
9. If the employee borrows Government equipment, he or she will borrow
and protect the Government equipment. Government owned equipment
will be serviced and maintained by the Government. If employee provides
own equipment, he/she is responsible for servicing and maintaining it.
10. Provided the employee is given at least 24 hours advance notice,
the employee agrees to permit inspections by the Government of the employee
alternate worksite at periodic intervals during the employee's normal working
hours to ensure proper maintenance of Government owned property and worksite
conformance with safety standards and other specifications in these guidelines.
Any accident or injury occurring at the alternate worksite must be brought
to the immediate attention of the supervisor. Because an employment-related
accident sustained by a telecommuting employee will occur outside the premises
of the official duty station, the supervisor must investigate all reports
immediately following notification.
11. The Government will not be liable for damages to an employee's
personal or real property during the course of performance of official
duties or while using Government equipment in the employee's residence,
except to the extent the Government is held liable by Federal Tort Claims
Act claims or claims arising under the Military Personnel and Civilian
Employees Claims Act.
12. The Government will not be responsible for operating costs,
home maintenance, or any other incidental costs (e.g., utilities) whatsoever,
associated with the use of the employee's residence. While telecommuting,
the employee does not relinquish any entitlement to reimbursement for authorized
expenses incurred while conducting business for the Government, as provided
for by statute and implementing regulations.
13. The employee is covered under the Federal Employee's Compensation
Act if injured in the course of actually performing official duties at
the official duty station or the alternate worksite.
14. The employee will meet with the supervisor to receive assignments
and to review completed work as necessary or appropriate.
15. The employee will complete all assigned work according to work
procedures mutually agreed upon by the employee and the supervisor and
according to guidelines and standards stated in the employee's performance
plan.
16. The employee's job performance will be evaluated on criteria and
milestones determined by the supervisor and will be consistent with those
of non-telecommuting co-workers.
17. The evaluation of the employee's job performance will be based
on norms or other criteria derived from past performance, occupational
standards, and/or other standards consistent with these guidelines.
18. The employee's most recent performance rating of record must be
fully successful or higher.
19. The employee's current performance plan contains performance standards
covering work completed at the official duty station as well as work completed
at the employee's alternate worksite.
20. The employee will apply approved safeguards to protect Government/agency
records from unauthorized disclosure or damage and will comply with the
Privacy Act requirements set forth in the Privacy Act of 1974, P.L. 93-579,
codified at section 552a, title 5 U.S.C.
21. The employee may terminate participation in telecommuting at any
time. Management has the right to remove the employee from a telecommuting
arrangement if the employee's performance declines or if the arrangement
fails to support organizational needs; such removal must be accomplished
in accord with established administrative procedures and union negotiated
agreements.
22. The employee agrees to limit her/his performance of her/his officially
assigned duties to her/his official duty station or to agency-approved
alternative worksites. Failure to comply with this provision may
result in loss of pay, termination of the telecommuting arrangement, and/or
other appropriate disciplinary action.
Employee's signature:
Date:
Supervisor's signature:
Date:
Part 3--Worksite Safety Checklist
This checklist is designed to assess the overall safety of the alternate
worksite. Each participant should complete and sign this safety checklist.
The employee's immediate supervisor should also sign.
Location of alternate worksite:
Description of designated work area:
For each question, circle YES or NO:
1. Is the space free of asbestos containing materials?
YES NO
2. If asbestos containing material is present, is it undamaged and in
good condition? YES
NO
3. Is the space free of indoor air quality problems?
YES NO
4. Is there adequate ventilation for the desired occupancy?
YES NO
5. Is the space free of noise hazards (noises in excess of 85 decibels)?
YES NO
6. Is there a potable (drinkable) water supply?
YES NO
7. Are lavatories available with hot and cold running water?
YES NO
8. Are all stairs with four or more steps equipped with handrails?
YES NO
9. Are all circuit breakers and/or fuses in the electrical panel labeled
as to intended service? YES
NO
10. Do circuit breakers clearly indicate if they are in the open or
closed position? YES
NO
11. Is all electrical equipment free of recognized hazards that
would cause physical harm (frayed wires, bare conductors, loose wires,
flexible wires running through walls, exposed wires fixed to the ceiling)?
YES NO
12. Will the building's electrical system permit the grounding
of electrical equipment? YES
NO
13. Are aisles, doorways, and corners free of obstructions to
permit visibility and movement? YES
NO
14. Are file cabinets and storage closets arranged so drawers
and doors do not open into walkways? YES
NO
15. Do chairs have any loose casters (wheels)? Are the rungs and
legs of chairs sturdy? YES
NO
16. Is the work area overly furnished?
YES NO
17. Are the phone lines, electrical cords, and extension wires
secured under a desk or alongside a baseboard?
YES NO
18. Is the office space neat, clean and free of excessive amounts
of combustibles? YES
NO
19. Are floor surfaces clean, dry, level, and free of worn or
frayed seams? YES
NO
20. Are carpets well-secured to the floor and free of frayed or
worn seams? YES
NO
Employee's signature:
Date:
Supervisor's signature:
Date:
SPECIAL NOTE: Supervisors are encouraged to conduct
an onsite inspection for any employee giving five or more "No" answers.
Employees are responsible for informing their supervisors of any significant
change.
Part 4--Employee/Supervisor Checklist
This checklist is designed to ensure that the participant and the immediate
supervisor/employee understand telecommuting policies and procedures.
NOTE: Questions 2, 3, and 4 may not be applicable. If
so, write N/A after the statement.
1. The employee has been provided with a schedule for hours/days
at the remote work site.
2. The following equipment has been issued to the employee and
has been documented by the agency:
Type of Equipment |
Issue Date |
Documented Date |
Computer |
|
|
Modem |
|
|
Fax machine |
|
|
Telephone |
|
|
Desk |
|
|
Chair |
|
|
Other |
|
|
3. Policies and procedures for care of equipment issued by the
agency have been explained and are clearly understood.
4. Policies and procedures covering classified, secure, or privacy
act data have been discussed and are clearly understood.
5. Requirements for an adequate and safe office space and/or area
have been discussed, and the employee certifies those requirements are
met.
6. Performance expectations have been discussed and are clearly
understood.
7. The employee understands that the supervisor may terminate employee
participation at any time, in accordance with negotiated agreement, if
applicable.
Employee's signature:
Date:
Supervisor's signature:
Date:
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