Reset Form
Telecommuting
Agreement Form
Kansas State University
Employee Name (please print):
First Name, Middle Initial, Last Name
Department/Unit: _____________________________
Employee ID:
Agreement Dates:
Begin Date
End Date
Dates for performance review: Mid-Year:________________
Renewal Date
Year End: _________________
The conditions for telecommuting are agreed upon by the employee, supervisor, department head, dean or vice president
and provost.
1. The employee will work at:
Street Address
City
State
Zip Code
Non-business people are not covered by the University and business meetings at the employee’s remote home site are
prohibited. The environment must be free of safety and fire hazards.
2. The employee's designated remote work location (e.g., home office section of living room, etc.) will include the following:
The employee is covered by worker’s compensation and must report accidents to supervisor. The University reserves the
right to inspect home offices in the case of injuries. Employees will be required to inspect their home office for safety and
ergonomics.
3. Indicate type of telecommuting:
_____ Regular, reoccurring of one or more days
_____ Alternative Workplace
Instructions for Question 4
FLSA Non-Exempt Employees: Advance supervisory approval is required to vary from the stated times.
FLSA Exempt Employees: a) If subject to a structured work schedule, complete all of question 4.
b) If not subject to a structured work schedule, complete only Total Telecommuting Hours/Day.
4. The employee's telecommuting work schedule will be:
Telecommuting Days:
Mon
Telecommuting Time:
Start Time:
Total Telecommuting Hours/Day:
Tue
Wed
Finish Time:
Thu
Fri
5. The procurement of software, hardware, communication lines, etc. will be made between the supervisor and the
employee. The employee is liable for any damage to University property resulting from abuse and is responsible for
securing data.
_____ No University equipment will be used at the remote work location.
_____ The following University equipment will be used at the remote work location:
Equipment: _____________________________________________________________________
Equipment: _____________________________________________________________________
6. The reimbursement of on-going expenses will be as follows: (Furniture and home expenses are not reimbursable.)
Supplies: _____________________________________________________________________________
Travel: _______________________________________________________________________________
7. Communication between the employee and his/her office (e.g., e-mail, voice mail, etc.) will be handled as follows:
8. Additional Terms:
The duties, obligations, responsibilities and conditions of employment with the University will not change, except the
department may require additional duties of the employee, including periodic written reports to the supervisor regarding
work progress. The employee will remain obligated to comply with all University and departmental rules, policies,
practices, and procedures, including safeguarding confidential information. The employee’s salary and benefits remain
unchanged.
This agreement is subject to the terms and conditions stated in the attached KSU Telecommuting Policy.
I have read and understand both the KSU Telecommuting Policy and this agreement with the understanding
that is not a replacement for dependent care, convalescing, or for caring of an ill family member. I agree to
abide by and operate in accordance with the terms and conditions outlined in both documents with the
understanding that these are not an amendment to any existing contract. This agreement may be terminated at
any time with advance notice by either me or the University. I acknowledge responsibility for contacting Human
Capital Services to determine tax jurisdiction, zoning and tax liability associated with working from my remote
office.
Employee Signature
Date
Supervisor Signature
Date
Department Head or Designee Signature
Date
Dean Signature
Date
Vice President or Provost Signature
Date
Send copy to: Human Capital Services, Edwards Hall, 1810 Kerr Drive, KSU, Manhattan, KS 66506 or FAX (785) 532-6095