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Temporary Telework Agreement Form
Home
Human Resources
Temporary Telework Agreement Form
Temporary Telework Agreement Form
Sam Turner
2021-02-11T15:35:42-07:00
Temporary Telework Agreement Form
The purpose of this document is for both the supervisor and the employee to have a clear, shared understanding of the employee’s TEMPORARY telework arrangement. Each telework arrangement is unique depending on the needs of the position, supervisor, and employee.
This telework agreement is not a contract of employment and does not provide any contractual rights to continued employment. It does not alter or supersede the terms of the existing employment relationship. The employee remains obligated to comply with all Burrell College rules, policies, practices, and instructions that would apply if the employee were working at their regular worksite.
Employee Telework Information
Employee Name:
*
First
Last
Job Title:
*
Department:
*
Supervisor:
*
First
Last
Arrangement requested by:
*
Employee
Department/College
Type of Telework Request:
*
Temporary
Full-Time
Part-Time
List Telework Schedule:
*
Location where telework will be performed:
*
List Specific Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Telework arrangement effective dates:
*
Date Format: MM slash DD slash YYYY
If end date is known:
Date Format: MM slash DD slash YYYY
Reason For Request:
*
Childcare
Mandated Virtual/Hybrid Schooling for School Age Children
COVID-19 Related
Please Explain:
*
Additional Information Required, please provide information for all school age children living within your home for which you are the legal parent/guardian:
*
Elementary School age child(ren) living at home
Middle School age child(ren) living at home
High School age child(ren) living at home
Other
Other (please explain):
*
Please select applicable option below
*
The employee is subject to a federal, state or local quarantine or isolation order related to COVID–19.
The employee has been advised by a health care provider to self-quarantine due to concerns related to COVID–19 (I.E. pre-existing conditions/high risk age group).
The employee is experiencing symptoms of COVID–19 and seeking a medical diagnosis.
The employee is caring for an individual who is subject to either number 1 or 2 above.
Please provide additional information on the reason selected above.
*
Job Duties
The general expectation for a telework arrangement is that employees will effectively accomplish their regular job duties, regardless of work location.
While on telework, an employee will:
remain accessible during the telecommute work schedule;
check in with the supervisor to discuss status and open issues;
be available for teleconferences, scheduled on an as-needed basis;
be available to come into the office if a business need arises;
request supervisor approval in advance of working any overtime hours (if employee is non-exempt); and
request supervisor approval to use vacation, sick, or other leave in the same manner as when working at employee’s regular work location.
Employee’s duties, obligations, responsibilities, and conditions of employment with Burrell College remain unchanged except those obligations and responsibilities specifically addressed in this agreement. Job responsibilities, standards of performance, and performance appraisals remain the same as when working at the normally assigned duty station. The supervisor reserves the right to assign work as necessary at any work site.
The parties acknowledge that this agreement may be evaluated on an ongoing basis to ensure that employee’s work quality, efficiency, and productivity are not compromised by the telework arrangement described herein.
Either the employee or Burrell College may end an employee requested telework arrangement at any time. This form does not apply to telework arrangements made through the disability accommodation process, although it may be utilized to initial the disability accommodation process. All employee-proposed changes are subject to supervisor approval.
Equipment and technology access
Burrell College supervisors will work with their employee(s) to determine appropriate and suitable equipment. In the spaces below, specify any equipment or technology access the employee will need to telework and whether it will be employee or Burrell College provided. In the event of equipment failure or service interruption, the employee must notify their supervisor immediately to discuss alternate assignments or other options. Internet access should be through the VPN system.
Employee agrees to protect Burrell College-owned equipment, records, and materials from unauthorized or accidental access, use, modification, destruction, or disclosure. Data security is vital. The precautions described in this agreement apply regardless of the storage media on which information is maintained, the locations where the information is stored, the systems used to process the information, or the process by which the information is stored.
Employee agrees to report to employee’s supervisor any incidents of loss, damage, or unauthorized access at the earliest reasonable opportunity.
Employee understands that all equipment, records, and materials provided by Burrell College shall remain the property of Burrell College. If employee utilizes their own equipment, he/she is responsible for servicing and maintaining it. Burrell College will not be liable for damages to an employee’s personal or real property during the course of performance of official duties ow while using college equipment in the employee’s residence. The college will not be responsible for operating costs, home maintenance or any other incident costs (i.e utilities) associated with the use of the employee’s residence. The college will not provide additional equipment such as desks, chairs, printers, office supplies, etc. to set up and maintain a home office, this is the employee’s responsibility.
Equipment Provided:
*
Telework - Timekeeping and Leave
Non-telework employees are expected to report to work as scheduled unless otherwise notified. Regular leave policies and procedures should be followed for employees who are unable to report to work.
Employees on telework should maintain accurate time records and supervisors are accountable for management of those records. Non-exempt employees should not perform any work related business when off the clock. Under the federal Fair Labor Standards Act (FLSA), non-exempt employees will be compensated for overtime that has been approved in advance by the supervisor in accordance with the provisions of the act.
Employees in exempt (salaried) positions are exempt from overtime regulations. Pursuant to established Burrell College policies, employees must obtain supervisory approval before taking leave.
Workers’ Compensation
Employee is covered by the Employer’s Workers’ Compensation insurance, if injured while performing official duties at the central workplace or alternate work location. Employee agrees to bring to the immediate attention of supervisor any accident or injury occurring at the alternate work location. Supervisor acknowledges and reports to Human Resources all accident and injury reports immediately following notification.
Safety Confirmation
Employee confirms that the alternate work location is, to the best of his/her knowledge, safe and free of recognized hazards that would cause physical harm (such as frayed, exposed or loose electrical wires; clean, dry, and level floor surfaces; phone lines and electrical cords are properly secured; etc.).
Name:
*
First
Last
Email:
*
Enter Email
Confirm Email
Signature
*
Date:
*
Date Format: MM slash DD slash YYYY
By signing this form electronically, it will be submitted and maintained by the Offices of Human Resources and IT.
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