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<br />Telework Agreement Form <br /> <br /> <br />Employee Name: Position: <br />Supervisor: Date: <br />Requested start date: Telework location: <br />Is this the employee’s home: ☐ Yes ☐ No If no, where is the telework location: <br />Type of Telework Arrangement requested: ☐ Routine ☐ Situational <br /> <br />If routine, what day(s) of the week you are requesting to work remotely: <br />☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday <br /> <br />Which of your job tasks and percentage of time for each could be done remotely? <br />____________________________________________________________________________________________________________ <br />____________________________________________________________________________________________________________ <br /> <br />By signing below, I confirm that I have read and understand the Telework Policy. I understand that prior approval is required and my <br />telework arrangement can be cancelled at any time for any reason, by the City or myself. <br /> <br />Employee Signature Date <br /> <br />Frequency and type of contact between employee and supervisor on remote days will be: <br />____________________________________________________________________________________________________________ <br />____________________________________________________________________________________________________________ <br /> <br /> <br />Supervisor Approval Date <br />Criteria for consideration: <br />☐ Employee has been employed with the City for at least three (3) months. <br />☐ Employee has a satisfactory work performance. <br />☐ Employee has a reliable broadband internet connection and a screenshot of speed test (completed by <br />www.highspeedinternet.com ) is attached. <br />☐ Employee has provided a picture of their remote workspace. <br /> <br />Equipment Provided by the City: <br /> <br />☐ Laptop ☐ Desktop ☐ Monitor ☐ Keyboard ☐ Mouse ☐ Other______________________ <br /> <br /> <br />Administrative Services Director Approval Date <br /> <br /> <br />Department Director Approval Date <br /> <br /> <br />City Administrator Approval Date <br /> <br />*Return completed form to the Administrative Services Director to be kept in the employee’s personnel file. * <br /> <br />To be completed by the Administrative Services Director