The success of telework is dependent upon a mutually beneficial arrangement for the department and the employee.
Before completing this form, the employee requesting a telework arrangement should review Telework Policy 4.26
. Both the abilities and characteristics of the employee and the nature of the work must be assessed by the supervisor before entering into a telework agreement. The form is designed to facilitate a positive and comprehensive discussion between the supervisor and the employee while assuring adherence to the University’s policy. If a telework arrangement is approved by the supervisor this form will accompany the agreement and will also serve to fully inform those involved in the approval process about the telework arrangements. It is important that all questions are answered and the supervisor and employee review the answers together to determine telework feasibility. In addition, the employee’s past work performance is part of the information to be reviewed by the supervisor with the employee before making a decision about a telework arrangement.
Telework is neither an entitlement nor an organization-wide benefit. In the event the supervisor and employee cannot reach agreement regarding the feasibility of telework, the supervisor’s judgment is final.
A. EMPLOYEE INFORMATION
Name:
Position Title:
Department:
B. POSITION SUMMARY
Date:
Length of Time in this Position:
Supervisor:
Briefly describe your job responsibilities and tasks or attach a current position description.
MERIT
027 Gilchrist  Cedar Falls, IA 50614-0034  Phone: 319-273-2422  Fax: 319-273-2927  http://www.uni.edu/hrs

C. TASK WORKSHEET
This section assesses the compatibility of your request with the needs and expectations of your specific position. Please answer the following questions completely.
List the proposed tasks you would work on at the alternate worksite. Identify how your supervisor could assess your performance on these tasks. Quantitative measures of performance are preferred.
Proposed Tasks Evaluative Criteria
1.
2.
3.
4.
5.
What is the address of the proposed alternate worksite?
Street Address:
State: Zip:
City:
Country:
Is this alternate worksite a requirement of the job?
Explain:
Yes No
Is a dedicated workspace available for your use? Describe the workspace in detail.
Before approval of a telework agreement you will be required to complete a self-certification regarding your alternate worksite. Based on the Telework Self-Certification Checklist , will you be able to certify the integrity of your alternate work site? If not, note any remediation of hazards you will need to complete and discuss the plan for remediation with your supervisor.
What is your proposed schedule of telework days and hours?
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6.
7.
Is travel required for the position you currently hold and are requesting a telework arrangement for? If so, to what extent is travel required? Please describe requirement in detail, listing frequency, location(s), purpose and any other details you feel are necessary.
Describe the type or level of access to data, records, reports, and other materials you need to complete your proposed work tasks at the alternate work site.
8. a. Describe your interactions and normal level of communication with co-workers, supervisors and other university employees required to complete your proposed work tasks.
8. b. How do you propose to maintain adequate communication with each of the groups if the telework arrangement is approved?
9.
10.
11.
12.
Do you supervise others? If so, how will you meet your supervisory responsibilities while teleworking?
Identify any distractions or obligations that might be distractions from your work at the alternate worksite. How will you manage these distractions to maintain both productivity and quality of work while teleworking?
Does your work involve substantial interaction with non-employees of the University? How will you maintain both the level and quality of customer service required while teleworking?
What are your plans for ensuring your telework arrangement does not inadvertently have a negative impact on your colleagues or their workload?
14. a. What equipment, supplies and services will be needed to support this telework request?
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14. b. Please refer to Paragraphs G. and I. under General Conditions of Telework Agreements in Policy 4.26
. Are you able to provide the required equipment and materials? What are you requesting the university provide to you?
* After completing the above information, submit this document to your supervisor and schedule an appointment to discuss your telework request.
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D. FINDINGS OF THE REVIEW
We, ________________________ and _______________________ have discussed this request to telework.
(employee) (supervisor)
At this time, the telework request is (please check):
• not recommended _____ , for the following reasons:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
• recommended _____ , with the following stipulations (if applicable):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________
Employee
________________________________________
Supervisor
_________________________
Date
_________________________
Date
Submission Instructions
If the employee is recommended for telework the completed Telework Request should accompany a completed Telework
Agreement and forwarded to Department Head/Director for review. The Telework Request and Telework Agreement will both be placed in the employee’s personnel file.
If the employee is not recommended for telework the completed Telework Request should be returned to Human
Resource Services and will be placed in the employee’s personnel file.
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