Teleworking Agreement
Employee Information
Employee Name
____________________________________
Job Title
____________________________________
Exempt or Non-Exempt
____________________________________
Employee Number
____________________________________
Employee Primary Work Location (Please
indicate campus: Main, East, CDC, MSC, etc.
and Office Number
____________________________________
Employee Work Phone (Please include
extension.)
____________________________________
Employee Home or Cell Phone
____________________________________
Supervisor
____________________________________
Conditions
Has the employee been employed for a
minimum of 12 months of continuous, regular
employment with CVCC?
Yes
No
Is the employee currently on an action plan?
Yes
No
Has the employee exhibited above-average
performance, as defined as receiving a rating
of “meeting expectationsor “exceeding
expectations,” in according with CVCC’s
performance appraisal process?
Yes
No
Please explain business necessity for
teleworking arrangement.
___________________________________
Proposed Work Agreement
Start Date
_________________________
_
End Date
__________________________
Schedule
__________________________
Proposed Alternative Work Site Address
__________________________
List any Supplies, equipment, or services to be provided
by the college at the teleworking site
__________________________
List any Supplies, equipment, or services at the
teleworking site that are deemed the
employee’s responsibility and are not provided at the
college's expense
__________________________
Describe how the department will ensure
appropriate supervision of the teleworking
employee while working at home (e.g. status
reports, conference calls, on-site meeting at the college
etc.)
__________________________
How frequently will the employee have face-to face
interaction with their supervisor at a
college office or facility? (eg. none, once per
week, once per month, X number of days per
month, etc. )
__________________________
List any Non-Negotiable Schedule Principals
(Everyone must attend Wednesday morning
staff meetings, everyone must be reachable by phone or
e-mail during regular business hours Monday through
Friday).
__________________________
Alternate work location examined with the
employee, to provide reasonable assurance
that materials, equipment and furniture
supplied to the employee at the Alternate Work Location
allow for successful completion of assigned work
responsibilities, comply with work related safety
standards, and minimize distractions to the work
environment?
Yes
No
All relevant IS/IT appropriate use and security
policies satisfied (For more information, see Policy 4.18
Technology Resources (Acceptable Use).
(http://www.cvcc.edu/About_Us/Policies/CVCCOperations-
Part-2.cfm#4.18)
Yes
No
Approval Certification
Employee
____________________________________
Supervisor
____________________________________
Human Resources
____________________________________
Dean
____________________________________
Appropriate Vice President
____________________________________
President
____________________________________
Date Received
____________________________________
Comments
____________________________________
30 Day Supervisor Review
Has the employee continued to comply with
all College rules, policies, practices, and
instructions?
Yes
No
Explanation
____________________________________
Has the quantity, quality, and timeliness of
work been maintained or enhanced?
Yes
No
Explanation
____________________________________
Has the work arrangement met the
expectations laid out in the original proposal?
Yes
No
Explanation
____________________________________
Has the work arrangement affected, either
positively or adversely, relations with
employee's colleagues or service to
customers?
Yes
No
Explanation
____________________________________
Has the work arrangement created or reduced
a need for additional staff, or caused a
department’s employees to generate or limit
overtime?
Yes
No
Explanation
____________________________________
Is the teleworking arrangement recommended
for continuation beyond the (30) day trial
period?
Yes
No
Explanation
____________________________________
Employee
____________________________________
Supervisor
____________________________________