APPENDIX D

REQUEST TO TELECOMMUTE

Employee=s Name

Date of Request

Employee=s First Line Supervisor

Employee=s Organization

I certify that my current rating of record is at least AFully Successful.@ initial

Proposed Start Date

No of Days at Alternate Worksite

Alternate Worksite (circle one)

Telecenter Or Home

Address of Alternate Worksite:

 

 

Phone # of alternate worksite

Fax # of alternate worksite

Circle days in office:

M T W Th F

E-mail of alternate worksite

Work assignment, communication methods, and work reporting:

 

 

 

 

 

I understand that if approved this agreement is subject to all guidelines, rules and regulations identified in Chapter 368, Telecommuting, of the Human Resources Handbook.

Employee=s Signature: Date:

9 Approve 9Disapprove (If disapprove, indicate reason below.)

Supervisor=s Signature: Date:

Reason request was not approved (attach additional sheet if needed):

 

 

 

 

 

Request to Terminate Agreement

Name of individual requesting termination of agreement:

 

 

 

 

 

Circle one : Supervisor or Telecommuter

Reason for termination of agreement - attach additional sheet if needed (2 weeks notice must be given when terminating an agreement)

 

 

 

Effective Date of Termination:

The supervisor will sign and return the form to the employee within five (5) business days, whenever possible.

Attach copy of this form to the telecommuting agreement between employee and supervisor. A copy of the request to telecommute should be forwarded to the Agency Telecommuting Coordinator in the Office of Human Resources and EEO after the supervisor has signed off.

cc: Office of Human Resources and EEO
      Attn: Telecommuting Coordinator
      1900 E Street, NW Room 1469
      Washington, DC 20415