Telework Eligibility Form

Please fill out this form completely to determine your eligibility for telework.

Employee Information

Name

    Job Title

      Department

        Manager’s Name

          Work Location

            Phone number

              Email

                Telework Details

                Requested Telework Schedule

                  • Full-time

                  • Part-time

                  • Flexible

                  If flexible, please specify:

                    Requested Telework Start Date

                      Job Suitability Assessment

                      Can your job tasks be performed remotely without impacting productivity?

                      Do you have access to the necessary technology and secure internet connection to perform work remotely?

                      Do you have a quiet, dedicated workspace suitable for telework?

                      Employee Agreement

                      I understand that submitting this form does not guarantee approval for telework. I agree to comply with all telework policies and guidelines if my request is approved.

                      Name:

                      Date:

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