Dla Form 1864 - Telework Request And Approval Form Page 2
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214. IF REGULAR AND RECURRING
a. TELEWORK TOUR OF DUTY (e.g., 8:30 A.M. - 5:00 P.M., including a one-half hour lunch period.)
b. Day(s) of the week employee will telework:
From:
To:
c. Number of Days per Week Telework is Recommended:
e. ALTERNATE WORK SITE ADDRESS:
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d. SELECT SCHEDULE TYPE:
Fixed schedule in accordance with local guidance and/or collective bargaining agreement.
Flexitime in accordance with local guidance and/or collective bargaining agreement.
AWS in accordance with local guidance and/or collective bargaining agreement.
15. IF PERIODIC OR INTERMITTENT
a. TELEWORK TOUR OF DUTY (e.g., 8:30 A.M. - 5:00 P.M., including a one-half hour lunch period.)
b. Dates employee will telework:
From:
To:
c. Number of Days per Week Telework is Recommended:
e. ALTERNATIVE WORK SITE ADDRESS:
1
2
3
4
5
d. SELECT SCHEDULE TYPE:
Fixed schedule in accordance with local guidance and/or collective bargaining agreement.
Flexitime in accordance with local guidance and/or collective bargaining agreement.
AWS in accordance with local guidance and/or collective bargaining agreement.
16. SIGNATURES AND RECOMMENDATION
a. EMPLOYEE'S SIGNATURE
b. DATE
c. SUPERVISOR'S SIGNATURE
d. DATE
e. SUPERVISOR'S RECOMMENDATION
Number of Days per Week Telework is Recommended:
Approved
Disapproved
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17. APPROVAL
a.
Number of Days per Week Telework is Authorized:
Approved
Disapproved (Explaining reason below.)
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b. APPROVING OFFICIAL
c. DATE
d. REASON FOR DISAPPROVAL:
PRIVACY ACT STATEMENT
AUTHORITY:
Public Law 106-346, Sec. 359, Transportation Appropriations Act, 2001 (Telecommuting).
PRINCIPAL PURPOSE(S):
Information is collected to register individuals as participants in the DLA alternate workplace program; to manage and document the duties of
participants; and to fund, evaluate and report on program activity. The records may be used by Information Technology offices for determining
equipment and software needs; for ensuring appropriate system safeguards are in place, and for managing technological risks and
vulnerabilities.
ROUTINE USES:
Information may be disclosed for any of the Routine Uses published by DLA and posted at
DISCLOSURE:
Disclosure is voluntary. However, failure to provide the requested information may result in our inability to include you as a participant in the
alternate workplace program.
DLA PRIVACY ACT SYSTEM NOTICE S330.10 APPLIES
Page 2 of 2
DLA FORM 1864, JUL 2004
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