Working from Home Agreement
APPLICATION
Employee details To be completed by the employee requesting to work from home
Name of employee:
Date of request:
Position:
School/Section:
Home Address:
Designated home based
work environment:
(specify work area in the home e.g. Study)
Supporting documents
The following may be required for this Working from Home Agreement to be reviewed:
WHAT
HOW
The employee completes and attaches the Home-Based Work
Complete the Home-based
Assessment Checklist
Assessment Checklist.
The employee and supervisor complete the Work Arrangements
Determine tasks, and
section (included in this agreement document)
supervision, training and
equipment required to
If applicable, the employee attaches any extra risk assessment
safely work from home.
documentation, refer Project and Task Risk Management Procedure
Outline schedules, contact
The employee and manager/supervisor complete the Communication
and reporting
Arrangements section (included in this agreement document)
arrangements.
The manager/supervisor completes the Notification Requirements
Determine who/what needs
to be notified
section (included in this agreement document)
APPROVAL
Manager / Supervisor Approval
Is the employee approved
to work from home?
To be completed by the employee’s Manager/Supervisor
Yes
No - Discuss the reason(s) why with
the employee
Working From Home
End date:
Arrangement - Start Date
Maximum term 3 years
Routine WHS inspection of To be conducted by the employee every:
home office
(Specify frequency; e.g. 6 months).
Manager /
Supervisor
Name
Signature
Date
Employee declaration
I, _______________________________ (name of employee), agree that all information provided in this
agreement is true and accurate in providing a workplace that is safe and without risk to my health. I
agree to comply with all requirements in this agreement and in the Working From Home Minimum
Standard, as well as all relevant University policies and procedures.
Employee’s signature
Date:
ASSESSMENT
Working from Home Agreement (November 2015)
Page 1
Working from Home Agreement
PART A – WORK ARRANGEMENTS: Proposed Tasks, Supervision and Training
To be completed by the employee’s Manager/Supervisor with the employee
Clearly outline the work / tasks to be performed by the employee in a home based work environment
If it is proposed the employee complete work from home other than general office / computer work, then a risk
assessment is required in accordance with the University’s WHS Project and Task Risk Management Minimum
Standard.
Is a Risk Assessment for any of the above tasks required?
Yes
No
Outline the supervision provisions for the above work?
Identify any specific training, instruction, information, experience, etc. the employee is required to
possess to safely carry out these tasks from home including how the employee will report any incident:
Outline any work expectations, and the way in which performance will be monitored and assessed (e.g.
measurement of output)
Working from Home Agreement (November 2015)
Page 2
Working from Home Agreement
PART B – EMPLOYEE ASSESSMENT: Workers Compensation and Rehabilitation
To be completed by the employee (and Workers’ Compensation staff if applicable)
Medical
Does the employee have a pre-existing injury
that may be aggravated by performing
University work tasks from home?
Has the employee seen a health / medical
professional about this issue?
Does the employee have any
recommendations from a health / medical
professional?
University Workers Compensation
approval (if applicable)
Result
Yes
No
Yes
N/A
No
Yes
N/A
No
Result
Action to be taken / Comments
If “yes”, discuss and answer questions below
with University Workers’ Compensation staff
prior to proceeding.
If “no”, skip to Part C. below.
Action to be taken / Comments
Is the employee approved to work from home?
(The suitability of the home based work
environment and tasks proposed to be Yes
undertaken from home, are to be reviewed as
part of the Workers Compensation staff
approval).
Workers Compensation staff
member name
No
Signature
Date
PART C – EQUIPMENT REQUIRED
To be completed by the employee’s supervisor with the employee
List of required equipment to perform work from home (tick if applicable)
To be provided by:
Employee University**
*
*
*
First aid kit
Smoke detector/ Fire alarm (functioning / in-date)
Fire controls (e.g. fire extinguisher, fire blanket) – Specify:
Head set
Computer
Computer screen
Mouse
Keyboard
Printer
Document Holder
Computer desk
Fully adjustable chair
Footrest
Filing / Storage equipment
Telephone
Stationery
Other? Specify below:
Emergency contact list
*Mandatory equipment requirements
** The University is responsible for maintaining University equipment.
Working from Home Agreement (November 2015)
Page 3
Working from Home Agreement
PART D – COMMUNICATION ARRANGEMENTS
To be completed by the employee’s supervisor with the employee
Employee name:
mobile phone number:
home phone number:
(Co-workers MUST NOT provide an employee’s home number to any other
person without the employee’s consent).
Employee work schedule by location Specify the days and/or hours the employee will be working in either
their University office or from home
Employee contact / reporting requirements
Diverted to their mobile phone
Diverted to their home phone
Diverted to / Answered by a co-worker:
Other (specify): ____________________
When Working From Home, is the employee required to call or report in regularly to verify they are ok?
Yes
No
If “YES”, complete details below:
Specify any relevant communication procedures required between the employee (when Working From Home)
and co-workers
When the employee is Working From Home,
their University office phone number must be:
If the employee or an employee’s co-worker has
any issues or concerns with the employee’s
Working From Home arrangement – please refer to:
(Name of Manager /
Supervisor)
Contact
Number
NOTIFICATION REQUIREMENTS
PART E – DETERMINE WHO / WHAT NEEDS TO BE NOTIFIED
To be completed by the employee’s Manager/Supervisor following approval for the employee to work from home.
In addition to the actions/control measures identified in any attached assessments, the following notification
actions must be undertaken BEFORE the employee can commence work from home:
Actions
Actioner
Date complete
Notify IT regarding access to the campus network
Manager / Supervisor
/ /
Notify the employee’s University work team of the Working From Home
Manager / Supervisor
“Communication arrangements” (Refer Part D above)
/ /
Employee to have an “Emergency Contact List” available in their home
Manager / Supervisor
office of numbers to call / persons to notify in an emergency situation.
/ /
Notify University Human Resources:
Manager / Supervisor
/ /
A copy of this Working From Home assessment is to be put on the employee’s personal file once all actions are
implemented.
Other? (specify below – attach extra pages if required)
Working from Home Agreement (November 2015)
Page 4