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Employee Checklist Template
Employee’s Initials: _________ 3
1. Employee is covered by the appropriate provisions of the Commonwealth’s Workers’
Compensation Program or the Virginia Sickness and Disability Program (VSDP), as
appropriate, if injured while performing official duties at the central workplace or alternate work
2. Employee agrees to certify that the work location is safe and free from hazards.
3. Employee agrees to bring to the immediate attention of his/her supervisor any accident or
injury occurring at the alternate work location.
4. Supervisor will investigate all accident and injury reports immediately following notification.
Employee will apply approved safeguards to protect agency or state records from unauthorized
disclosure or damage, and will comply with the privacy requirements set forth in the state law
and the Department of Personnel and Training’s Policies and Procedures Manual.
1. Employee agrees to adhere to applicable guidelines and policies.
2. Agency concurs with employee participation and agrees to adhere to applicable policies and
3. Employee may terminate participation in telecommuting at any time unless it was a condition
of employment. Two weeks notice to the agency is recommended.
4. Agency may terminate employee’s participation in telecommuting at any time. (Employees
may be withdrawn for reasons to include, but not limited to, declining performance and
organizational benefit). Two weeks notice to the employee is recommended when feasible.
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source: resources.dhrm.virginia.gov
Employee Checklist Template