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Telecommuting Pilot Program Application
A. Employee Information (to be completed in full by the applicant)
Please check one: New Application Application for Renewal
Name:
Job Title
Work Desk Phone Number:
Salary Grade:
Work Unit
Bargaining Unit
Work Cell Phone Number:
Supervisor/Manager:
Official Work Site:
Current Work Schedule (Hours/Days):
Employee Email Address:
Emergency contact information: (voluntary)
Name:____________________________________
Telephone:
Please provide a description of your Current Job Duties:
Describe the job duties you would perform while telecommuting:
Are you currently serving a probation period? Yes No
B. Equipment
Do you have a state-issued Laptop? Yes
Do you have a per
sonal computer (PC)? Yes
No
No Inventory Tag #
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C. Personal Privacy Protection Law Notification
The information you are providing will be used to determine your eligibility to participate in the Telecommuting
Pilot Program. This information will be retained by your agency. Failure to provide the requested information
may result in a delay in processing or denial of your application.
It is the responsibility and the intent of the State of New York to fully comply with the provisions of article 6-A of
the Public Officer’s Law, the Personal Privacy Protection Law. The Personal Privacy Law protects you from the
random collection of personal information by state agencies. The law enables you to access and/or correct
information on file which pertains to you. It also regulates disclosure of personal information to persons
authorized by law to have access for official use.
D. Attestation
I am in receipt of, have read and agree to adhere to the Telecommuting Pilot Program Bulletin, my
agency/campus employee handbook and the following additional policies if any (to be completed by
manager) ________________________________________________________________________
_________________________________________________________________________________________
By entering your name, you are signing this document and agree to abide by all rules and guidelines.
Employee Name Date
*Submit the application to your supervisor for review.
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This section to be completed by supervisor:
I have reviewed the application and the employee
Meets criteria
Does not meet criteria
(If this option is selected, you must complete both boxes below)
By entering your name, you are signing this document.
Supervisor Name ______________________________ Date ___________________________
Supervisor Title:
Supervisor Email Address:
*Supervisor: Submit application to your President's Council Designee.
Choose all that apply:
Performance concerns
Duties require physical presence at official work site
Technology/equipment limitations
Operational hardship
Task cannot be quantified and/or evaluated
Other
Provide additional information to
support your decision:
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This section to be completed by President's Council Designee:
Approve
Disapprove (If this option is selected, you must complete both boxes below)
By entering your name, you are signing this document.
President's Council Designee Name _____________________________ Date _______________________
President's Council Designee Title:
President's Council Designee Email Address:
*President's Council Designee: Submit form to the Director of Human Resources
or designee for final processing.
Distribution: Personnel File
Employee
Supervisor
Choose all that apply:
Performance concerns
Duties require physical presence at official work site
Technology/equipment limitations
Operational hardship
Task cannot be quantified and/or evaluated
Other
Provide additional information to support your decision:
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