Attachment A
East Stroudsburg University
Telecommuting Agreement Form
General Information
Employee Name _________________________________________________________
Job Title: _______________________________________________________________
Phone: _________________________________________________________________
Telecommuting Agreement
The following constitutes an agreement on the terms and conditions of the telecommuting
arrangement between East Stroudsburg University and _______________________.
1. The employee has requested to utilize the option of telecommuting and
understands and agrees to adhere to his/her responsibilities and requirements as
outlined in the Policy on Telecommuting, East Stroudsburg University concurs
with the employee’s participation and agrees to adhere to its responsibilities and
requirements as outlined in the Policy on Telecommuting.
2. The employee has elected to telecommute for one day a week beginning on the
date of ___________________.
This agreement may be extended beyond the initial period if agreeable to both
East Stroudsburg University and the employee. In such a case, the terms of this
agreement should be reviewed and updated annually. This agreement can,
however, be terminated at the sole discretion of the University at any time for any
or no reason.
3. The employee will work at the remote work location from ____ am/pm to ____
am/pm on the following day _________________.
4. The employee’s remote work location is located at the following address:
___________________________
___________________________
___________________________
5. For IRS reporting and travel reimbursement purposes, the employee’s “tax home”
is where the employee does most of his/her work and physically spends most of
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his/her time. The employee’s tax home should, for the time being, be East
Stroudsburg University.
6. The East Stroudsburg University Human Resources Office will maintain a copy
of the employee’s telecommuting agreement and schedule. The employee’s time
and attendance will be recorded as performing duties at the regular worksite.
7. The employee must obtain supervisory approval before taking leave in accordance
with established policy, by signing this form, the employee agrees to follow
established procedures for requesting and obtaining approval of leave.
8. The employee agrees that telecommuting shall not be used as a substitute for child
care, elder care, or used to tend to other personal matters.
9. East Stroudsburg University owned equipment will be serviced and maintained by
the University. VPN access and required software will also be provided as
necessary. The employee agrees to follow all PASSHE security and data
confidentiality policies and procedures, and state and federal laws to protect
System data. It is also understood that such equipment and software are the sole
and exclusive property of East Stroudsburg University and are subject to the same
business and proper use of technology as if it were located on site. The employee
further agrees to utilize system proved technology when accessing confidential
data, and understands that any equipment that is used by an employee (personal or
System resources) is subject to e-discovery and Right-to-Know requests.
10. The employee agrees to permit inspections of the remote work location by East
Stroudsburg University to ensure proper maintenance of University owned
property and compliance with safety standards, or in the event of injury to
complete an incident report and conduct an incident investigation.
11. The employee is covered by workers’ compensation if injured in the course of
performing official duties at the regular or remote work location, during regular
working hours. Any accident or injury occurring at the remote work location must
be brought to the immediate attention of the supervisor and the East Stroudsburg
University Human Resources Office. Because an employment-related accident
sustained by a telecommuting employee may occur outside the premises of the
regular worksite, the supervisor or designee must investigate all reports
immediately following notification and access to the remote work location shall
be provided. The employee understands that failure to provide access is grounds
for immediately terminating the telecommuting arrangement.
12. East Stroudsburg University will not be liable for damages to an employee’s
personal or real estate property during the performance of work duties or while
using University equipment at the remote work location.
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13. East Stroudsburg University will not be responsible for operation costs, home
maintenance, or any other incidental costs (i.e., utilities) associated with the
remote work location. While telecommuting, the employee does not relinquish
any entitlement to reimbursement for authorized expenses submitted in
accordance with travel policies.
14. The employee will meet with the supervisor to receive assignments and to review
completed work as needed and necessary.
15. The employee’s job performance will be evaluated on criteria, milestones, and
deliverables as determined by the supervisor and will be consistent with those of
non-telecommuting coworkers.
16. The employee’s most recent performance rating must be “Exceeds Expectations”
or higher and has not been subject to any disciplinary action in the past twelve
months.
17. The employee will apply approved safeguards to protect East Stroudsburg
University records from unauthorized disclosure, loss, or damage and will comply
with the security requirements set forth by East Stroudsburg University.
18. The employee or supervisor may terminate the telecommuting agreement at any
time. Management may terminate the telecommuting arrangement immediately if
the employee’s performance declines or if the arrangement fails to support
organizational needs.
APPROVALS:
Employee: ____________________________ Date: _____________________
Supervisor: ____________________________ Date: _____________________
Director of Human Resources: ____________________ Date: ________________
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East Stroudsburg University
Worksite Safety Checklist
This checklist is designed to assess the overall safety of the remote work location. Each
participant must complete and sign this safety checklist prior to beginning a
telecommuting arrangement.
Location of remote work location:
________________________________________________________________________
________________________________________________________________________
Description of designated work area:
________________________________________________________________________
________________________________________________________________________
For each question, circle YES or NO:
1. Is the space free of hazardous materials? YES NO
2. Is the space private and in a low-traffic area? YES NO
3. Is the space free of indoor air quality problems? YES NO
4. Is there adequate ventilation for the desired occupancy? YES NO
5. Is the space free of noise hazards? YES NO
6. Are all stairs with four or more steps equipped with handrails? YES NO
7. Are all circuit breakers and/or fuses in the electrical panel labeled as to intended
service? YES NO
8. Do circuit breakers clearly indicate if they are in the open or closed position?
YES NO
9. Is all electrical equipment free of recognized hazards that would cause physical harm
(i.e., frayed wires, bare conductors, loose wires, flexible wires running through walls,
exposed wires fixed to the ceiling)? YES NO
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10. Will the building’s electrical system permit the grounding of electrical equipment?
YES NO
11. Are aisles, doorways, and corners free of obstructions to permit visibility and
movement? YES NO
12. Are file cabinets and storage areas arranged so drawers and doors do not open into
walkways? YES NO
13. Do chairs have any loose casters (wheels)? Are the rungs and legs of chairs sturdy?
YES NO
14. Is the work area properly furnished? YES NO
15. Are the phone lines, electrical cords, and extension wires secured under a desk or
alongside a baseboard? YES NO
16. Is the office space neat, clean, and free of excessive amounts of combustibles?
YES NO
17. Are floor surfaces clean, dry, level, and free of worn or frayed seams? YES NO
18. Are carpets well-secured to the floor and free of frayed or worn seams? YES NO
Signatures:
Employee: _______________________________ Date: ___________________
Supervisor: _______________________________ Date: ___________________
SPECIAL NOTE: Supervisors are required to conduct an on-site inspection for any
employee giving five or more “No” answers and corrective actions must be taken prior to
the start of a telecommuting arrangement. Employees are responsible for informing
his/her supervisors of any significant changes to the remote work location.
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East Stroudsburg University
Employee/Supervisor Checklist
This checklist is designed to ensure that the employee and supervisor understand the
telecommuting policies and procedures.
1. The employee and supervisor have established a work schedule for hours and day
at the remote location
2. the following equipment has been issued to the employee and has been
documented by East Stroudsburg University:
TYPE OF
EQUIPMENT
Computer
MAKE
MODEL
SERIAL
NUMBER
ISSUE DATE
Scanner
Fax Machine
Telephone
Printer
Other:
Other:
Other:
3. Policies and procedures for care of equipment issued by East Stroudsburg
University and have been explained and clearly understood
4. Policies and procedures covering confidential information and the security of this
data have been discussed and are clearly understood.
5. Requirements for an adequate and safe office space and/or area have been
discussed, and the employee certifies that those requirements are met.
6. Performance expectations have been defined and are clearly understood
7. The employee understands that he/she or the supervisor may terminate the
telecommuting agreement at any time. The employee further understands that
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management may terminate the telecommuting arrangement immediately if the
employee’s performance declines or if the arrangement fails to support
organizational needs. The employee also understands that all equipment issued to
him/her by East Stroudsburg University is the property of East Stroudsburg
University and must be returned immediately upon request.
SIGNATURES:
Employee: _____________________________ Date: _________________
Supervisor: _____________________________ Date: _________________
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