Instructions

If an employee and his or her supervisor decide to pursue the possibility of the employee telecommute, this form is to be completed by the employee, their supervisor, their department head, and otherwise as noted

  1. Part 1, General Terms and Conditions: The employee (teleworker) should review Part 1,which ensures that each County teleworker has read PMR 27, Telework Policy, and has agreed to abide by the general terms and conditions established therein and as described below.
  2. Part 2, Specific Terms and Conditions: The employee, together with the departmenthead or designee (such as the immediate supervisor), should complete Part 2, that defines the employee’s specific terms and conditions for telework. Additionally, check which of the four boxes in the “Approval” section at the end of the form apply.
  3. Part 3, Ergonomic Self-Certification Checklist: If the teleworker may use his/her home as an office, then complete Part 3 and abide by the rules set forth. Otherwise, skip Part 3. Part 3 is the “Ergonomic Self-Certification Checklist” which certifies that the teleworker’shome office conforms to the factors listed.
  4. IST Approval: If telework involves remote access into the County’s network, then this form must next be submitted to the IST Help Desk so that the appropriate staff can be assigned to review and approve (by signature) that technical requirements have been met.
  5. Teleworker Certification: The teleworker should then certify (with signature) that he/she agrees to follow all applicable requirements related to teleworking.
  6. Department Head Approval: Next, the department head (or designee) must provide his/her signature approval.
  7. HR Filing: Finally, the completed form (original) should be forwarded to Human Resources, where it will be placed in the employee’s official personnel file.

Part 1: General Terms and Conditions

  1. I have read and agree to abide by the rules established for telework, as defined in PMR 27, Telework Policy.
  2. Upon the receipt of written authorization, I may use my own equipment and/or software to telework. The County assumes no responsibility for the maintenance or repair of my own equipment of software.
  3. If there are any equipment or software failures while I am working at home, I am responsible for immediately informing my supervisor. I also understand that I may be asked to return to my principal office until repairs are completed or a substitute has been provided. I further understand that any repairs made by the County will be performed at a location designated by the County.
  4. I am to report any problems I may be having with, or because of, teleworking to my supervisor (such as relatives or friends always dropping in and causing distractions from work, absence of child care, feeling isolated and needing more interaction with my co-workers, etc.).
  5. If I have any questions regarding any of the above or regarding teleworking, I will check with my supervisor.