Rev. 04/14/2020
Request Form
The purpose of this document is to assist both the supervisor and the employee with a clear
understanding of the employee’s telework arrangement during emergencies. This form does not apply
to telework arrangements made through the disability accommodation process. Each telework checklist
is unique depending on the needs of the position, supervisor, and employee. This form is not
mandatory, nor is it a contract of employment and does not provide any contractual rights to continued
employment. It does not alter or supersede the terms of the existing employment relationship.
Employee Telework (work-at-home)Information:
Employee Name: Banner ID:
Job Title: Department:
Arrangement requested by:
Employee Department
Location where telework(work-at-home) will be performed: Telework (work-at-home) effective dates:
(if end date is known)
Job Duties:
The general expectation for a telework (work-at-home)arrangement is that employees will effectively accomplish
their regular job duties, regardless of work location.
While on telework (work-at-home), an employee will:
a. remain accessible during the telework work schedule;
b. check in with the supervisor to discuss status and open issues;
c. be available for teleconferences, scheduled on an as-needed basis;
d. be available to come into the office if a business need arises;
e. request supervisor approval in advance of working any overtime hours (if employee is non-
exempt); and
f. request supervisor approval to use vacation, sick, or other leave in the same manner as
when working at employee’s regular work location.
Employee’s duties, obligations, responsibilities, and conditions of employment with NM Tech remain
unchanged except those obligations and responsibilities specifically addressed in this arrangement. Job
responsibilities, standards of performance, and performance appraisals remain the same as when working
at the normally assigned duty station.
3. The parties acknowledge that this arrangement may be evaluated on an ongoing basis to ensure that
employee’s work quality, efficiency, and productivity are not compromised by the telework arrangement
described herein.
Specify a date to discuss the effectiveness of the telework arrangement, or enter N/A.
Telework (work-at-home) date:
Human Resources
New Mexico Tech
801 Leroy Place
Socorro, NM 87801
Phone: (575) 835-5206
Fax: (575) 835-5337
Rev. 4/14/2020
Equipment and technology access.
1. NM Tech supervisors will work with their employee(s) to determine appropriate and suitable equipment. In
the event of equipment failure or service interruption, the employee must notify their supervisor
immediately to discuss alternate assignments or other options.
Employee agrees to report to employee’s supervisor any incidents of loss, damage,
unauthorized acc at the earliest oportunity.
Employee understands that all equipment,
records, and materials provided by NM Tech shall remain
the property of NM Tech.
In the spaces below, specify any equipment or technology access the employee will need to
Timekeeping & Leave
Regular leave policies and procedures should be followed for employees who are unable to report to
Employees in exempt (salaried) positions are exempt from overtime regulations. Pursuant to established
NM Tech policies, employees must obtain supervisory approval before taking leave.
Incident Reports
The employee shall report any job-related injuries that occur in the course and scope of employment while
teleworking at the earliest reasonable opportunity.
Policies and Procedure Acknowledgements Initials
I have read and understand the NM Tech Telework (work-at-home) Policy.
Employee signature: Date:
Supervisor signature: Date:
Return the signed form to Human Resources. Electronic signatures are acceptable.
To:, Director of Human Resources
cc:, Associate Director of Human Resources
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