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Employee Checklist Template
Employee’s Initials: _________ 2
1. Employee will meet with the supervisor to receive assignments and to review completed work
as necessary or appropriate.
2. Employee will complete all assigned work according to work procedures mutually agreed upon
by the employee and the supervisor, and according to guidelines and expectations stated in
the employee’s performance plan.
3. Supervisor will evaluate employee’s job performance according to the employee’s
performance plan (on PP&E form).
4. Employee agrees to limit performance of his/her officially-assigned duties to the central
workplace or agency-approved alternate work location. Failure to comply with this provision
may result in loss of pay, termination of the telecommuting agreement, and/or appropriate
disciplinary action.
1. All salary rates, leave accrual rates, and travel entitlements will remain as if the employee
performed all work at the central workplace.
2. Employee who works overtime that has been requested by his/her supervisor and approved in
advance will be compensated in accordance with applicable law and state policy.
3. Employee understands that supervisor will not accept the results of unapproved overtime work.
By signing this form, employee agrees that failing to obtain proper approval for overtime work
may result in his/her removal from telecommuting and/or appropriate action.
4. Employee must obtain supervisory approval before taking leave in accordance with
established office procedures. By signing this form, employee agrees to follow established
procedures for requesting and obtaining approval of leave.
1. Employee who borrows agency equipment agrees to protect such equipment in accordance
with agency guidelines. State-owned equipment will be serviced and maintained by the
2. If employee provides own equipment, he/she is responsible for servicing and maintaining it.
3. Neither the agency nor the state will be liable for damages to an employee’s personal or real
property during the course of performance of official duties or while using state equipment in
the employee’s residence.
4. Neither the agency nor the state will be responsible for operating costs, home maintenance, or
any other incidental costs (e.g., utilities) associated with the use of the employee’s residence.
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source: resources.dhrm.virginia.gov
Employee Checklist Template