Employee Checklist Template - Free Download | Page 3
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Employee's Initials: ________ 1
Attachment A
SAMPLE TELECOMMUTING WORK AGREEMENT
The following constitutes an agreement on the terms and conditions of telecommuting between:
Agency Date
Employee Date
1. Employee agrees to participate in telecommuting and to adhere to applicable guidelines and
policies. ____ YES ____ NO
2. Agency concurs with employee participation and agrees to adhere to applicable guidelines and
policies. ____ YES ____ NO
3. Employee agrees to participate in telecommuting for an initial period not to exceed one year,
beginning __________________ and ending ___________________.
NOTE: This agreement may be extended beyond the initial one year period, if agreeable to the
agency and to the employee. In such case, the terms of this agreement should be reviewed and
updated as necessary.
4. A copy of the Telecommuting Policy has been given to the employee.
____ YES ____ NO
WORK LOCATION/SCHEDULE
1. Employee’s central workplace is: _____________________________________________
2. Employee’s alternate work location is at: _______________________________________
________________________________________________________________________
.
Describe in detail the designated work area at the alternate work location. ____________
________________________________________________________________________
________________________________________________________________________
3. At the central workplace, employee’s work hours will normally be from _______ to ______,
on the following days: ______________________________________________________.
4. At the alternate work location, employee’s work hours will normally be from __________ to
_________, on the following days: ____________________________________________.
5. Employee’s time and attendance will be recorded the same as performing official duties at the
central workplace.
6. Supervisors will maintain a copy of telecommuter’s work schedule, and employee’s time and
attendance will be recorded the same as if performing official duties at the central workplace.
source: resources.dhrm.virginia.gov
