Name of Employee Making Proposal _______________________ Department ______________
Title of the Position __________________________________Job/Position #_______________
What is the telephone number of your telecommuting site?______________________________
What is the e-mail address of your telecommuting site?_________________________________
What is the fax number (if applicable)?______________________________________________
Which days/times do you propose working from home?
Which of your current duties do you propose to do from home?
Is there a sufficient amount of that work to support working at the telecommuting site for the
specific time and amount of time you propose? ___Yes ___ No
Do these duties lend themselves to independent accomplishment and can they be accomplished
with equipment available in the home (or provided by the university)? ___ Yes ___ No
Can these duties be accomplished without access to paper files, network software and daily mail
that are not at the home worksite? ___ Yes ___No
Do you supervise others? ___ Yes ___No If yes, how do you plan to maintain supervisory
responsibilities and ensure connectedness with those you supervise?
Are you part of a project team? ___ Yes ___ No If yes, are you familiar with Oncourse and
its use for making communication and document sharing easier? ___Yes ___No If not will
you investigate and learn to use Oncourse (if applicable) before starting to telecommute? ___
Please identify any obligations/distractions that might make working at the telecommuting site
difficult, and explain how you plan to handle.
Potential Obligation/Distraction Plan to Handle
How will this arrangement help you to be an even more productive employee?
How will department costs be affected (savings? additional costs?)? Details please.
How do you propose that your phone calls, campus mail, customer visits and faxes be handled in
Phone Calls –
Campus Mail –
Customer Visits –
I am a good candidate for this flexible work arrangement because (personal characteristics, work
I have considered the needs of our department/office/unit/etc., and the expectations of my
position and have identified several potential benefits (improved cost effectiveness/customer
service/productivity) to this arrangement. They are as follows:
What are the potential concerns relating to the department if this request is granted, and what are
your suggested solutions?
Challenge Possible Solution
Lack of supervisor’s presence during work time - –
Communication with customers, coworkers, etc. -
That I will not combine both a compressed work week or job sharing with telecommuting.
That telecommuting is not a substitute for dependent care and, thus, have dependent care
arrangements made, so that I will not serve as the primary caregiver for a dependent during work
time and can be available for work as needed.
To refrain from picking up work from the office on my telecommuting days or having others
deliver work to me because I share the concern about the potential for Workers’ Compensation
events and travel costs/liabilities. I will take work home with me as I leave the main office on
days that I am there and will not split days between the two sites unless required by supervisor.
That travel and mileage between home and office once a day will be noncompensable as this is
ordinary commuting. For example, if you are asked to come into the office once on a normal
telecommuting day, your travel time and mileage would not be compensated. If, however, you
are asked to travel further than you would normally have had to travel to come into the office for
work or are asked come into the office more than once a day, such travel time is in excess of the
normal trip to and from the office and will be compensated. See Staff Policy 4.3 E. for more
details on travel.
To permit inspections of the worksite by the University, with 24-hour notice, to ensure proper
maintenance of University property and worksite conformance with safety standards, etc.
To accurately record my time using the TIME system or other system used in the department and
understand that if I am overtime-eligible, federal law mandates that I must record the actual time
spent providing work services and must clock out for personal phone calls, etc.
To protect access to and confidentiality of information by labeling all work files and keeping
(when not in use by the employee) in a locked file cabinet to which only I have the key; by
refraining from moving items that contain personal/confidential/proprietary information,
electronic or otherwise, to the alternate work site without prior approval of my supervisor; by
turning off the computer when not in use: by keeping any laptop which contains
confidential/proprietary information locked in a file cabinet when not in use and under my close
watch at other times; to use stringent passwords, security codes, a password-protected hardware
firewall, a software firewall, updated virus protection/patches and encryption for electronic
information; and to bring all items that contain personal/confidential/proprietary information and
need to be shredded to main office and shred, place in office shredding container, or shred on
home cross-cut shredder.
To provide security of information and protection from computer viruses, worms, etc. by
providing computer protection software and doing daily updates, if I am providing the computer
that will be used for work purposes. The brand/version of computer protection software that I
will provide is Norton Antivirus Corporate Edition version 10.0.1.100 which is available for
download free online to all staff via http://iuware.indiana.edu/ (or the campus bookstore). I have
the minimum computer requirements to install the software (Windows 2000 or Windows XP
and 64 MB of disk space).
To use a high-speed modem so that I can work efficiently.
To confer with my departments technology specialist and install the required software. Note:
Most departments use Microsoft Office Suite which can be downloaded from
http://iuware.indiana.edu/ site for free.
To use only secure lines (not the Internet) to send work information, log off if I leave my work
area, safeguard passwords to work files, scan diskettes for viruses before and after each
telecommuting session, refrain from using borrowed software and avoid loading non work-
related software on a computer provided by employer.
To use a modem saver or phone line tester to test the digital phone line before plugging in my
laptop (if applicable) so that the laptop modem won’t be “fried.”
To allow those at the office access to the phone number of my alternate work site. I also
understand that caller ID may allow those I call to identify my phone number. I ___ permit
___ do not permit my number to be given to those who don’t work in my department.
That the main office (not my telecommuting location) is still my official duty station and
understand that all pay, special salary rates, leave and travel entitlements are based on the official
To refrain from using my car for university business unless specifically authorized by my
To immediately report any accidents/injuries/workplace violence/harassment at the alternate
work site to my supervisor and to Employee Relations at 274-8932 in Human Resources
To abide by governmental codes, rules, regulations and zoning ordinances, as well as, tax
implications associated with home offices. Tax forms 4562 (and companion instructions,
publication 534, and publication 587 from the IRS may be of interest).
To take responsibility for taxes, if applicable.
To assume liability for equipment/property damages and injuries to myself, third persons and/or
members of my family at the alternative worksite except as provided for under the HR policy on
To indemnify and hold harmless the University and its staff members, agents, officers, trustees,
successors and assignees (in their official and individual capacities) from and against any and all
claims, demands, judgments or liabilities (including any related losses, costs, expenses and
attorney fees), resulting from, arising out of or in connection with any injury to person (including
death) or damage to property, caused directly or indirectly by the services provided hereunder by
the staff member or by the staff member’s willful misconduct or negligent acts or omissions in
the performance of the staff members duties and obligations under this agreement except where
such claims, demands or liability arise solely from the gross negligence or willful misconduct of
the University. By signing below I certify that I have checked my homeowner’s/renter’s policies
to be sure that my home office is covered.
I have read and understand the above. If I felt I needed more information, I have sought that out
and understand it. I have taken any steps needed to be in compliance with items outlined above.
I propose that this telecommuting arrangement begin __________________. Note: Starting at
the beginning of the pay period may be advantageous, especially if there is a change of FTE.
I certify that my answers to the above are true. I have read and agree to the above. If I felt I
needed more information, I sought that out and now understand fully. I would like to discuss
this proposal with you further and address any concerns that you may have. I understand that
you are responsible for the success of this organization and must determine whether or not this
plan fits appropriately within the goals for the office. I also understand that approval of this
proposal means that we will pilot the arrangement, and that we may need to make adjustments to
this plan or I may need to return to my original work schedule/arrangement if this is not going
well or the needs of the organization require this on a temporary or permanent basis.
Signature of Employee ____________________________________ Date __________________
Please attach: A copy of your official job description and a list of duties not on the
official job description
Work-at-Home Health and Safety Checklist (required for all
Is Telecommuting Good for Me?
Copy of last performance appraisal