Telework Application
Date ______
I. Employee Information
Name ______Address ______
City & State ______Zip code ______
Agency/Division ______
Job Title ______
Office Phone ______
Telework Office Phone ______
Supervisor (direct report) ______
Office Phone ______
II. Telework Information
Proposed Start Date ______
Current Commute Option (i.e. car, rideshare, mass transit, bus) ______
Average daily travel time (one way) ______
Average daily trip mileage (one way) ______
Average Gas Mileage (MPG) ______
Average Annual Leave Hours used ______
Is this your first experience of Teleworking? ______
III. Telework Schedule
Proposed Telework Days(circle all that apply)
Monday Tuesday Wednesday Thursday Friday Variable (specify) ______
Alternate Telework Days(circle all that apply)
Monday Tuesday Wednesday Thursday Friday Variable (specify) ______
Proposed Daily Schedule
Total hours per day _____ Beginning ______(am/pm) Ending ______(am/pm)
Core hours you can be reached: Beginning ______(am/pm)Ending ______(am/pm)
What results/accomplishments/tasks do you expect to complete on Telework days?
IV. Dependent Care
Do you have dependents requiring care during telework hours? _____
If yes, do you have dependent care available during your telework hours? _____
V. Circle all equipment/services to be used at telework site
Phone Voice Mail Second phone line Office Furniture Pager Fax Machine Typewriter
Desktop Computer Laptop Computer Printer Internet Scanner Desk ISDN Line
Broadband Line Video Conferencing Cell phone Answering Machine other______
VI. Applicant Acceptance of Telework Policy
I have read and understand the telework policies. I understand that my application for telework does not constitute a formal agreement for telework unless authorized by my supervisor’s signature appearing below. I have received and completed the alternate site safety checklist. I understand that my participation in telework is a management option, voluntary and contingent upon my suitability to successfully complete my required job tasks from an alternate location.
Employee Signature: ______Date: ______
Supervisor Signature: ______Date: ______