Fill and Sign the Telecommuting Worksheet Form

Telecommuting Worksheet Please answer the following questions completely. 1. List the proposed tasks that you will do at the telecommuting site. ____________________________________________________________________ ____________________________________________________________________ 2. Identify the evaluative outcomes you would propose for yourself. Consider how your supervisor could assess your performance in meeting or exceeding expectations. Be as quantitative as possible. Proposed Tasks % of Time Evaluative Criteria __________________________________ ____________ _________________ __________________________________ ____________ _________________ __________________________________ ____________ _________________ 3. Identify the address of the proposed telecommuting site. _________________________ ______________________________________________________________________ 4. List the proposed schedule of work hours: ____________________________________ ______________________________________________________________________ 5. Describe the telecommuting work site, including arrangements to maintain the confidentiality and security of the records, reports and data. _____________________ _____________________________________________________________________ 6. Describe your availability for staff meetings, discussions with co-workers and supervisor, and other group times. ____________________________________________________ ______________________________________________________________________ 7. Identify any distractions or obligations that might make working at the telecommuting site difficult and your plans for handling these. ____________________________________ ______________________________________________________________________ 8. If you are supervising others, describe how you will maintain those responsibilities and ensure connectedness with those you supervise. Address subordinates’ abilities to work independently. _________________________________________________________ ______________________________________________________________________ 9. Address how service may be affected. _______________________________________ ______________________________________________________________________ 10. How will you insure that the telecommuting arrangement does not inadvertently have a negative impact on your colleagues or their workload? __________________________ ______________________________________________________________________ 11. Identify the equipment you have available at the telecommuting site.  Computer/terminal [ ] Yes [ ] No  Printer [ ] Yes [ ] No  High-speed internet connection [ ] Yes [ ] No  Additional telephone line [ ] Yes [ ] No  Software [ ] Yes [ ] No  Desk and chair [ ] Yes [ ] No  Filing cabinet [ ] Yes [ ] No  Photocopier [ ] Yes [ ] No  Fax [ ] Yes [ ] No  Internet access service [ ] Yes [ ] No  Long distance service [ ] Yes [ ] No  Other (please specify): __________________________________________ 12. List any other equipment needed to support this arrangement.  __________________________________________________  __________________________________________________  __________________________________________________  __________________________________________________ Date: ________________________ _____________________________ (Printed Name of Employee) __________________________ (Signature of Employee) After completing the above, submit the document to your supervisor and schedule an appointment to discuss your telecommuting request.