Telecommuting Request Form printable pdf download

Telecommuting Request Form

Telecommuting Request Form (Sample)

This form is used to assess the benefits of telecommuting for particular

positions and employees. This form is intended to provide employees and

supervisors with the criteria for successful telecommuting arrangements and to

ensure a consistent and fair method of processing telecommuting requests.

Employee Name: __________________________________________________________________

Position Title: _____________________________________________________________________

Office Location: ___________________________________________________________________

Office Phone: ____________________________________________________________________

Supervisor Name: _________________________________________________________________

Home Location: ___________________________________________________________________

Home Phone Number: ______________________________________________________________

Miles from office to home: ___________________________________________________________

1. Briefly describe your current job duties:

(Use additional sheets if necessary)

2. Rate each of the following job characteristics according to your current job requirements. If there is a high

requirement for this aspect of your job, then mark an “X” in HIGH column. If it has little importance, mark an “X”

in the LOW column.

Job Requirements

HIGH

LOW

1. Ability to control and schedule work.

2. Clear and understandable work assignment objectives.

3. Work independently.

4. Concentration required.

5. PC or computer terminal work.

6. Amount of face-to-face contact required.

7. Amount of telephone communication required.

8. Amount of in-office reference material required.

9. Amount of data security required.

Note:

High rating for items 1 through 5 and low ratings for items 6 through 9 indicate likelihood that the job is compatible with a telecommuting

arrangement.

3. Describe how your current job duties will be adapted to telecommuting.

Telecommuting Request Form