University of Houston System
COVID-19 Telecommuting Form
I. Short-term Work Arrangement – Related to COVID-19
1. This is an agreement between _________________(“the department”) and _________________ (“Employee”) to
establish the terms and conditions for performing work at an alternate work site.
2. This agreement will begin on _________ and anticipated to continue through_________.The following conditions
a. Employee’s telecommuting schedule is _____________________.
b. Employee’s regular telecommuting site location is _____________________.
c. Employee’s contact phone number is _____________________.
3. While telecommuting, Employee will:
a. remain accessible by phone or electronically during the telecommute work schedule;
b. be responsible for establishing effective communication among co-workers and customers and to check in
with the supervisor to discuss status and open issues;
c. be available for teleconferences, scheduled on an as-needed basis;
d. request supervisor approval in advance of working any overtime hours (if employee is non-exempt);
II. Safety & Equipment; Information Security
1. Employee agrees to maintain an adequate, safe, and secure work environment and to report work-related injuries to
Employee’s supervisor at the earliest reasonable opportunity. Employee agrees to hold the University harmless for
injury to others at the alternate work site.
2. Regarding space and equipment purchase, set-up, and maintenance for telecommuting purposes:
a. Employee is responsible for providing space, telephone, printing, networking and/or Internet capabilities at
the telecommute location, and shall not be reimbursed by the employer for these or related expenses.
Internet access must be via DSL, Cable Modem, or an equivalent bandwidth network.
b. Employee agrees to protect University-owned equipment, records, and materials from unauthorized or
accidental access, use, modification, destruction, or disclosure.
c. Employee understands that all equipment, records, and materials provided by the University shall remain
the property of the University.
d. No Protected Health Information or otherwise confidential information should be kept on personal electronic
e. Employee must follow all other software licensing and copyright laws, as well as all precautions and
I hereby affirm by my signature that I have read this Telecommuting Agreement and understand and agree to all
of its provisions.
Employee’s Name and PS ID
Supervisor’s Name Date
Please note this form is not mandatory and should be retained in your department files.