Employee Telecommuting Request and Work Plan
Employee Information:
Last Name: _________________________ First Name: ___________________ Employee ID #: ________
Department: ________________________Employment Type: ____ Exempt ____ Non-Exempt
Campus Phone Extension: ____________________ Cell Phone: _____________________________
Telecommuting allows employees to perform a portion of their job responsibilities at an alternative
work site while maintaining a full-time employment schedule. The employee's duties, obligations,
responsibilities and conditions of employment with the College remain unchanged when the
arrangement involves only a change in work location.
The decision to permit an employee to telecommute is at the discretion of the employee’s manager
and is informed by the nature of the employee’s position and the feasibility of performing the role
successfully in an alternative environment. A telecommuting arrangement is most appropriate for a
position that has clearly defined tasks, measurable work activity, and does not require the employee to
be present in the office during all normal business hours. The general expectation for a telecommuting
arrangement is that the employee will effectively accomplish their regular job duties, regardless of
work location.
A telecommuting arrangement will be reviewed with consideration given to the following:
It supports the department and College’s goals, including cost effectiveness, excellent service,
and high productivity
The impact on the equitable work distribution, productivity, and communication needs among
Appropriate performance standards and measures will be in place
Established means of supervision, communication, and systems of accountability
Steps for Requesting A Telecommuting Arrangement
Read the Telecommuting policy.
Initiate a conversation with your manager regarding telecommuting.
Submit the Employee Telecommuting Request and Work Plan to your manager for review.
If an agreement is reached, document the details of the telecommuting arrangement including
maximum length of time and equipment needs.
Additional approval by an academic or administrative officer is required.
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Type of flexible work option being requested:
Current work schedule: ________________________________________
Proposed Start Date of Telecommuting Work: _____________________
Consider the following when completing the information below:
Ability to control and schedule work
Clear and understandable work assignment objectives
Ability to work independently
Concentration required
Equipment needed to complete work task
Amount of face-to-face contact required
Amount of telephone communication required
Amount of in-office reference material required
Amount of data security required
Work plan for how to accomplish current duties. (Attach additional pages if necessary)
Describe how your current job duties will be adapted to telecommuting:
Describe the impact on co-workers and internal/external customers and how any negative impact will be
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Describe how routine work-related communication (email, telephone, voice mail, meetings, etc.) will be
lease describe any other special work-related task or duties that may need to be considered during the
telecommuting period.
roposed work schedule:
Sunday ______________________ Thursday ______________________
Monday ______________________ Friday ______________________
Tuesday ______________________ Saturday ______________________
Wednesday ______________________
Employee and Manager should discuss expectations of maintaining the security of work-related materials
including documents saved on a computer or taken off-site and safe destruction of confidential work-
related documents.
Employee Responsibilities:
Establish a space conducive to productive work and maintain safe work conditions.
Maintain accurate time reporting (including entering work time, vacation time, and sick time).
Obtain prior management approval for overtime.
Maintain asset, data and information security. This includes, but is not limited to, operating
systems, antivirus/antispyware protection, and secured network access.
An employee whose position requires access to electronic files or business applications is expected
to personally provide internet service. To enable maximum productivity, a persistent broadband
internet connection is required for all telecommuters. Lack of high-speed internet service could
adversely impact an employee’s productivity making the ability to telework unlikely.
Business visits or meetings shall not be held at the alternative work site without approval of
employees’ manager.
Telecommuting work must be conducted only at pre-approved work site, and never during transit
to or from the telecommuting work site.
Do not permit other persons to utilize the work space during business hours. The employee is liable
for any injuries sustained by visitors to their work site.
Comply with all safety policies and procedures, including immediately reporting injuries sustained
during working hours to your supervisor.
Employee is responsible for insuring all equipment, not owned by Millsaps College, used for
telecommuting. The College will not be responsible for operating costs, home maintenance,
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property or liability insurance, or other incidental expenses (utilities, cleaning services, etc.)
associated with the use of the employee's residence.
Manage dependent care or personal responsibilities in a way that allows for successful meeting of
ob responsibilities. A telecommuting arrangement is not meant as a substitute fo
hild/dependent care.
An employee can request the discontinuation of a telecommuting arrangement before its scheduled time
of expiration. A telecommuting arrangement can be discontinued by management with a two week notice
when possible, though an immediate and unanticipated operational need may require the immediate
suspension of the telecommuting arrangement.
I have read and understand Millsaps’ Telecommuting Policy and the considerations outlined in the
Employee Telecommuting Request and Work Plan.
Employee Signature: ________________________________ Date: ___________________
nager: Consider performance standards and measures under the proposed telecommuting work plan.
Communicate with employee expectations regarding deadlines, communication, in-office attendance for
meetings and other necessary work.
Manager Comments:
nager Approval: ________________________________ Date: ___________________
This arrangement will be reviewed periodically to evaluate success of the plan by the Manager and
ate for next review: _________________________________
Date for next review: _________________________________
Date for next review: _________________________________
epartment should retain a copy of the Employee Telecommuting Request and Work Plan Form and send
original to Human Resources, 150972. The approved form will be placed in the employee file.
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