Appendix15

RenewalofTelework Agreement

Dateofrequest: (applications shouldbe made atleast two(2)monthsin advance)

FullName

IDCardNo.

Ministry/EntityGrade/Position

Department/Directorate

OfficeTel.

REQUEST

IamherebyrequestingarenewaloftheTeleworkAgreement,effectivedate(original effectivedate ofteleworkagreement)andlastrenewedon(lastrenewaldate(deleteifnot applicable),foraperiod ofoneyearwitheffectfrom(insert effectivedate).

Reason for request: (Reason forrequestisnotmandatory,howeveritisrecommendedthatareasonisstatedasthiswillassistmanagement inmakinganinformeddecision).

Document(s)supportingrequestenclosedwithapplicationYesNo

TeleworkAgreementRenewalrequestedunderthesametermsandconditions

TeleworkAgreementRenewalwithmodifications

(IftheTeleworkRenewalisrequestedwithmodifications,pleasespecifythemodificationsrequestedbyfillingonlytherelevantfieldsbelow.Pleasecrossoutwherenotapplicable).

Full NameMinistry/ Entity Grade/Position

Home/MobileNo.

Department/Directorate

WINTERWORKSCHEDULE:1October–15June

(specifythehourstobeworkedattheOffice/Telework)

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Office
Telework

SummerWorkSchedulesameasWinterWorkSchedule.YesNo

(Ifyes,thereisnoneedtofillintheSummerWorkSchedulebelow).

Totalno.ofhoursbeingteleworked:

Corehoursattheplaceofwork:

SUMMERWORKSCHEDULE:16June–30September

(specifythehourstobeworkedat the Office/Telework)

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Office
Telework

Totalno.ofhoursbeingteleworked:

Corehoursattheplaceofwork:

FUNCTIONSTOBEPERFORMED:

(List allthetasksthataretobeperformedremotelyfromtheoffice)

THESETASKS SUPERSEDETHE PREVIOUSLY AGREEDTASKS

THESETASKS AREADDITIONAL TO THEPREVIOUSLY AGREEDTASKS

LOCATIONDETAILS:

(Pleasespecifytheaddressfromwhereyouwill bee-workingandwhereyouneedthee-workfacilitiesinstalled)

HARDWARE

(Ticktheoneapplicable)

Atwork,doyouuseadesktoporalaptop?DesktopLaptop

SOFTWARE

(Pleaselist specificsoftware/services/applications you needaccessto)

IneedaccesstothestandardOfficeAutomationsoftwareonly.

InadditiontothestandardOfficeAutomationsoftware,Ineedaccesstothefollowing:

CONNECTIVITYREQUIREMENTS

(Ticktheoneapplicable)

Tier1:Internet,E-mail

Tier2:Internet,E-mail,VPN

Tier3:VPN

Approved

NotApproved(ifnotapprovedplease providereason)

Employee:

Fullname

Signature

Date

Director/HeadofDepartment:

Fullname

Signature

Date

HRManager/DirectorresponsibleforCorporateServices:

Fullname

Signature

Date

PermanentSecretary:

Fullname

Signature

Date

PermanentSecretary’sendorsementisthe effectivedateoftheTeleworkAgreement.

TheinformationsuppliedinthisapplicationformshallbeusedexclusivelybytheemployingMinistryforrecordkeepingandverificationpurposes.Personalinformationprovidedonthisapplicationformisprotected,andusedinaccordancewiththeprovisionsoftheData ProtectionAct.