BOP Program Statement 3630.02 § 22

her/his official duty station or to agency-approved alternative worksites. Failure to comply

with this provision may result in loss of pay, termination of the telecommuting arrangement, and/or

other appropriate disciplinary action.

Employee's Signature: Date:

Supervisor's Signature: Date:

Pag e 3 of 4

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4. Is there adequate ventilation for the desired occupancy? YES NO

5. Is the space free of noise hazards (noises in excess of 85 decibels)? YES NO

6. Is there a potable (drinkable) water supply? YES NO

7. Are lavatories available with hot and cold running water? YES NO

8. Are all stairs with four or more steps equipped with handrails? YES NO

9. Are all circuit breakers and/or fuses in the electrical panel labeled as to

YES

NO

Part 3–Worksit e Safet y Checklist

This checklist is designed to assess the overall safety of the alternate worksite. Each

participant should complete and sign this safety checklist The employee's immediate supervisor

should also sign.

Location of alternate worksite:

Description of designated work area:

For each question, circle YES or NO:

1. Is the space free of asbestos containing materials? YES NO

2. If asbestos containing material is present, is it undamaged and in good condition? YES NO

3. Is the space free of indoor air quality problems? YES NO

intended service?

10. Do circuit breakers clearly indicate if they are in the open or closed position? YES NO

11. Is all electrical equipment free of recognized hazards that would cause physical

harm (frayed wires, bare conductors, loose wires, flexible wires running through

walls, exposed wires fixed to the ceiling)?

12. Will the building's electrical system permit the grounding of electrical

YES NO

equipment? YES NO

13. Are aisles, doorways, and corners free of obstructions to permit visibility and

movement? YES NO

14. Are file cabinets and storage closets arranged so drawers and doors do not open

into walkways? YES NO

15. Do chairs have any loose casters (wheels)? Are the rungs and legs of chairs

sturdy? YES NO

16. Is the work area overly furnished? YES NO

17. Are the phone lines, electrical cords, and extension wires secured under a desk

or alongside a baseboard? YES NO

18. Is the office space neat, clean and free of excessive amounts of combustibles? YES NO

19. Are floor surfaces clean, dry, level, and free of worn or frayed seams? YES NO

20. Are carpets well-secured to the floor and free of frayed or worn seams? YES NO

Employee's Signature: Date:

Supervisor's Signature: Date:

SPECIAL NOTE: Supervisors are encouraged to conduct an onsite inspection for any employee giving

five or more "No" answers. Employees are responsible for informing their supervisors of any

significant change.

Pag e 4 of 4

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Part 4–Employee/Superviso r Checklist

This checklist is designed to ensure that the participant and the immediate supervisor/employee

understand telecommuting policies and procedures.

NOTE: Questions 2, 3, and 4 may not be applicable. If so, write N/A after the statement.

1. The employee has been provided with a schedule for hours/days at the remote work site.

2. The following equipment has been issued to the employee and has been documented by the agency:

Type of Equipment Issue Date Documented Date

Computer

Modem

Fax machine

Telephone

Desk

Chair

Other

3. Policies and procedures for care of equipment issued by the agency have been explained and are

clearly understood.

4. Policies and procedures covering classified, secure, or privacy act data have been discussed and

are clearly understood.

5. Requirements for an adequate and safe office space and/or area have been discussed, and the

employee certifies those requirements are met.

6. Performance expectations have been discussed and are clearly understood.

7. The employee understands that the supervisor may terminate employee participation at any time, in

accordance with negotiated agreement, if applicable.

Employee's Signature: Date:

Supervisor's Signature: Date:

Pag e 5 of 4

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BP-A0901 Telecommuting Request Form CDFRM

JUN 10

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Section I. (To be completed by the Employee)

To: Employee’ s Supervisor

Please consider my request for a telecommuting work schedule. I have completed and attached the

following documents for your review and signature.

U.S. DOJ Flexible Work Options Request Form

Telecommuting Agreement Form

Memorandum of Understanding

Employee’s Name:

Position Title & Grade:

Supervisor’s Name:

Division/Branch/Section:

Section II. (To be completed by the Division and forwarded to Central Office Employee Services Department)

To: HRMD/Centra l Offic e Employe e Service s Department

The attached Telecommuting Request is forwarded for your review and consideration. I have reviewed

the request, and made the following recommendation. (Note: If disapproved, explanation is required in

Section II of the DOJ Flexible Work Options Request Form)

( ) Approved ( ) Disapproved

Supervisor’s Signature Date

( ) Approved ( ) Disapproved

Assistant Director’s Signature Date

Section III. (To be completed by HRMD)

To: Assistan t Director, HRMD

The attached Telecommuting Request is forwarded for your consideration. The request has been

reviewed by the Employee Services Department and is in compliance with policy.

Employee Services Department (Signature and Title) Date

( ) Approved ( ) Disapproved

Assistant Director, HRMD (Signature) Date

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BP-A0926 BOP Secure Portal Request and Agreement Form CDFRM

JUN 10

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Add User Delet e User Modif y User

A – User Information

1. Full Name: 2. User ID:

3. E-mail Address: 4. Div./Facility:

5. I understan d that at anytim e I am asked or require d to perfor m officia l dutie s using

Remot e Acces s durin g non-duty hours, I will contac t my superviso r for approva l and wil l

formall y documen t the time spent performin g those function s via a reques t for compensator y

time or overtim e whicheve r is most appropriate.

(User Initials):

B - Porta l Access/Application s Required

Justificatio n for Remot e Acces s (includin g any justificatio n for remot e SENTRY):

Defaul t Porta l acces s include s acces s to Corel Offic e Suite, Sallypor t and GroupWise.

Indicat e other application s require d (mark w/ an ‘X’):

• SENTRY: (List secur e verbs require d if any: )

• Teamsite:

C – CEO Authorization

Printe d Name: Phone:

Title: Division/Facility:

Signature: Date:

D – Assistan t Director/Regiona l Directo r Authorizatio n (Require d for Remot e SENTRY)

Printe d Name: Phone:

Signature: Date:

E – IPPA USE ONLY

Approved: Yes No

Signature:

Date: Thomas R. Kane, Asst. Director for IPPA

(Complete d forms shoul d be sent via GroupWis e to: BOP-IPP/Compute r Help Desk; Faxe s

will not be accepted)

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Rules of Behavior and Security Agreement

Governing the Use of

the BOP Secure Access Portal

The purpos e of this agreemen t is to maintai n a usabl e computin g environmen t for all BOPNet

users. BOPNe t Networ k Administrator s have the authorit y to disabl e login s immediatel y for

failur e to compl y with this agreement. The followin g provision s are mandatory. Policy

will be strictl y enforce d in this area in light of the IT securit y implication s for non-compliance.

The followin g rules apply to any remot e acces s connectio n to BOPNe t via the BOP’s Secure

Acces s Porta l (hereafte r “the portal”):

1) All usage of the porta l must be consisten t with the user’ s officia l duties:

2) A BOPNe t user accoun t (user ID & password ) is solel y for the use of a single

individual, the perso n for whom the accoun t was approved. Sharin g or loanin g user

login informatio n is strictl y prohibited.

3) The porta l may only be used for lawfu l purposes. Transmissio n of any materia l in

violatio n of any US or state regulatio n is prohibited. This includes, but is not limite d

to: copyrighte d materia l (unles s authorize d by the copyrigh t holder), threatenin g or

obscen e material, or materia l protecte d by trade secre t or unfai r trade practice s laws.

4) The followin g action s are prohibited:

a) Attempt s to circumven t establishe d securit y procedure s (includin g those outlined i n

Progra m Statemen t 1237.13, Information Security, or it’s successor), or to obtai n acces s

privilege s to which a user is not entitled.

b) Attempt s to modif y BOPNe t compute r system s or softwar e in any unauthorized

manner.

c) Unauthorize d access, alteration, or destructio n of anothe r user' s data, programs, o r

electroni c mail.

d) Attempt s to adversel y affec t the availabilit y or qualit y of servic e of the BOPNet

Network.

5) Users shall not conduc t a remot e porta l sessio n in a publi c place (airports, hotel

lobbies, air planes, trains, internet/WiF i cafes, publi c libraries, etc.).

6) Users shall not conduc t a remot e porta l sessio n in the compan y of anyone, to include

Departmen t of Justic e employees, who do not have authorize d acces s to BOPNet.

7) Becaus e users are not in a controlle d environmen t (institution, Regiona l Office,

Centra l Office), users must take extrem e cautio n to ensur e BOPNe t informatio n is not

disclose d inappropriately. These precaution s include:

•

Safeguardin g your remot e acces s password;

• Being aware of those aroun d you;

• Being aware of your surroundings;

• Keepin g your remot e devic e in your possessio n or locke d in a safe place not

frequente d by the genera l publi c at all times; and

• At all times, keepin g all print-outs and diskette s generate d from a remot e session

in your possessio n or locke d in a safe place not frequente d by the genera l public.

8) The BOP will provid e license d softwar e for connectio n of approve d governmen t computers

or laptop s to BOPNe t via the portal.

9) Users must emplo y commonsens e protection s on their governmen t laptops, governmen t PCs

or home network s to avoid compromisin g BOPNe t due to virus infections, trojans, and/or

intrusio n attempt s by hackers. Such securit y precaution s includ e the use of current

anti-virus software/definition s encryptio n and a firewall.

User Acknowledgment

I, the undersigned, understan d the requirement s state d above and agree to compl y with its

provisions. I fully understan d that my authorizatio n to use the BOPNe t Remot e Access

syste m does NOT automaticall y grant or includ e authorizatio n for overtim e compensation.

I understand that at anytime I am asked or required to perform official duties using Remote

Access during non-duty hours, I will contact my supervisor for approval and will formally

document the time spent performing those functions via a request for compensatory time or

overtime whichever is most appropriate.

If the propriety of any situation is unclear, I will ask for clarification from the

Network Management Branch and/or the Information Security Program Office rather than make

any assumptions.

Printed Name: Phone:

Title: Division/Facility:

Signature: Date:

BP-A1086 ANNUAL LEAVE CREDIT FORM

FEB 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

I. Eligibility

Annual Leave Category Eligibility Requirements

6 hours 3 years but less than 15 years of experience directly related to the position for which the

applicant is being appointed.

8 hours 15 or more years of experience directly related to the position for which the applicant is being

appointed.

II. Credit for Service

Position Beginning Date Ending Date Total Years/Months

Total amount of service for positions directly related to position selected for:

Meets the Leave Category for ___ 4 hours ___6 hours ___8 hours

III. Attachments

Documents Check Off

Annual Leave Credit Justification (with all signatures)

Signed Annual Leave Credit Form

OF-612 Optional Application/Resume with hours worked and dates of employment

Signed Service Agreement

Position Description with Cover Page

Signature of HR Representative Date

Printed Name of HR Representative

PDF Prescribed by P3630

BP-A1087 ANNUAL LEAVE CREDIT SERVICE AGREEMENT

FEB 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

I understand that in order to retain this service credit, I must complete one (1) full year of continuous service with the

Department of Justice. In the event I leave prior to the completion of one full year of employment, the Department of

Justice will recalculate my service credit.

I understand that I will retain all accrued or accumulated annual leave if I transfer within the Department of Justice to a

position to which annual leave may be transferred, or I will receive a lump-sum payment if I separate from the Federal

service or move to a position to which annual leave cannot be transferred.

I understand if I am placed in a leave without pay (LWOP) status while on the service agreement, the service period

must be extended by the amount of time placed in the LWOP status.

The only exceptions to extending the service agreement when placed on LWOP are as follows:

If I separate or am placed in a LWOP status to perform service in the Uniformed Service and later return by exercising

restoration rights.

If I separate or am placed in a LWOP status due to an on-the-job injury that entitles me to injury compensation, and I

later recover, and return to work.

Applicant’s Signature Date

Applicant’s Printed Name

Signature of HR Representative Date

Printed Name of HR Representative

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BP-A1088 Federal Bureau of Prisons New Written Agreement – Additional Tour of

FEB 16 Overseas Duty for Home Leave Entitlement

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

In order to acquire eligibility for travel and transportation expenses pursuant to Title 5, U.S. Code, Section 5728, and

the Federal Travel Regulation, I, , agree to remain in the

service of the Government at for an additional months following my return

to, after home leave travel, unless transferred at the convenience of the

Government.

It is understood that should I violate this agreement, I become obligated to refund to the Government all costs incurred

on my behalf for travel, transportation, and related expenses as prescribed in the Federal Travel Regulation, unless

separated for reasons beyond my control and acceptable to the BOP.

Signature/Date

WITNESS:

Signature/Title/Date

PDF Prescribed by P3630

BP-A1090 COMPRESSED WORK SCHEDULE (CWS) AGREEMENT

MAR 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

My signature on this memorandum affirms that I agree to work a compressed 80-hour

biweekly work schedule. I understand that this schedule consists of diversified hours,

i.e., four 10-hour days a week, or eight 9-hour days and one 8-hour day in a biweekly

pay period.

I acknowledge that the compressed work schedule has been fully explained and is

understood as an option to the regular work schedule. Additionally, I agree to return to

standardized working hours should this schedule have an adverse impact on the

operation of the institution as determined by the CEO.

I understand and agree to the conditions of alternative work schedules as stated in 5

CFR part 610, Subpart D, as they apply to premium pay and leave administration.

In addition, I understand that most periods of travel or training can be accommodated

without changing the compressed schedule. However, if the travel or training will

conflict with a scheduled non-work day, the schedule will be altered to change the non-work day for that pay period.

____________________________ ______________________________

Name: Title:

____________________________ ______________________________

Signature: Date:

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BP-A1091 COMPRESSED WORK SCHEDULE (CWS) REQUEST

MAR 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

FOR, CHIEF EXECUTIVE OFFICER

THROUGH: Supervisor/Manager

Title

FROM: (Employee’s name)

Title

SUBJECT: Compressed Work Schedule Request

This serves as an official request for a Compressed Work Schedule for, Employee name,

Title, Section/Department. The type of schedule being requested is

5/4/9-hour or

4/10-hour days per week.

The proposed compressed work schedule will be implemented the first full pay period

after approval.

(Sample is below, input preferred schedule)

Sun Mon Tue Wed Thur Fri Sat

(1st"'Week) Off Off 7:00 am 7:00 am to 7:00 am to 7:00 am to Off

to 4:30 pm 4:30 pm 4:30 pm 4:30 pm

Off 7:00 am to 7:00 am to 7:00 am to 7:00 am to 7:00 am to Off

(2nd Week) 4:30 pm 4:30 pm 4:30 pm 4:30 pm 3:30 pm

Disapproved:

Approved:

Name, Chief Executive Officer

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BP-A1092 COMPRESSED WORK SCHEDULE (CWS)

MAR 16 SUPERVISORY PRE-IMPLEMENTATION QUESTIONNAIRE

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

INSTRUCTIONS: In order to assess the effectiveness of the compressed work

schedule, you are to examine the results of the CWS relative to proposed goals,

objectives and expectations for undertaking the compressed schedule. As the

supervisor, you are to complete this questionnaire with the request for a compressed

work schedule. In completing this questionnaire, give careful consideration to existing

sources of information on the operation of the department/unit, including program or

operational reviews, climate surveys, institution character profiles, and employee

performance evaluations. As needed, evaluations may be conducted to assess the

outcomes of the CWS relative to the goals, objectives and expectations detailed in

this questionnaire.

1. Department/Unit Productivity: What do you anticipate will happen to the level of

productivity in the department/unit? Include as many measurable outcomes as

possible. For example, do you expect overtime costs to decrease, or an increase in

coverage during shift changes?

2. Level of Service Provided to the Public: To what extent will the level of services

furnished to the public increase or diminish?

3. Cost of Agency Operations: To what extent will the cost to the agency increase

or decrease?

Supervisor’s Name: Department/Section:

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BP-A1093 REQUEST FOR RESTORATION OF FORFEITED

MAR 16 ANNUAL LEAVE

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Employee Name and Title:

To: Human Resource Manager

Institution: SSN:

Leave Year Leave Forfeited:

Annual Leave Ceiling:

Annual Leave Balance:

Annual Leave Forfeited:

Supporting Data:

List periods of annual leave approved, scheduled, and forfeited. Provide dates and

hours that were approved.

I was unable to take this leave for the following reason(s): Note: Unforeseen work

demands, sick leave, and administrative error are acceptable reasons. Please be

specific; use additional sheets as necessary. State any attempts to reschedule leave.

Employee Signature:

Date:

Certification by the Supervisor:

Annual Leave Forfeited:

Date exigency ended:

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The annual leave hours in excess of the maximum permissible were forfeited at the end

of the leave year and were the result of the detailed reason(s) claimed by the

employee.

Any correction(s) or adjustment(s) are included in comments below and have been

considered in excess annual leave hours certified. Describe any attempts to

reschedule leave.

Comments: (Use additional sheets as necessary)

Signature:

Date:

Authorization for Restoration by Designated Official:

Signature:

Title: Date:

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BP-A1094 SUPERVISORY ASSESSMENT OF COMPRESSED WORK SCHEDULE

MAR 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

INSTRUCTIONS: The purpose of this questionnaire is to evaluate the effectiveness of the compressed

work schedule on the department/unit which you directly manage. To properly assess the overall

utility of the compressed work schedule, it is important we obtain objective data from supervisors.

Management decisions regarding the continuation of the compressed work schedule will be based, in

part, on the results of this questionnaire. Please answer the following as they relate to the impact of

the CWS on agency operations, specifically, costs, productivity, and level of service.

As a result of your department's/unit's participation in a compressed work schedule, indicate with a

percentage in the appropriate box, the extent to which the following increased or decreased as a

result of the CWS in your department/unit.

The percent increase or decrease should be based on comparing data before implementation of the

CWS to data from the period during the CWS. This data can consist of employee or

departmental/unit records (e.g. sick leave hours, overtime hours, performance records, etc.). For

example, to determine the extent sick leave has changed, you should compare employee records of

sick leave use prior to implementation to records of sick leave use during the CWS. Data can also

consist of your observations (e.g. observations of fatigue, etc.). For example, to assess changes in

the level of fatigue, you could observe the level of fatigue of your staff under the CWS and compare

it to your observations of staff fatigue prior to implementation. Because observations are open to

subjective biases. You should attempt to collect as much objective data and information as possible.

Following the completion of the table, you will be required to provide data to document any changes

in costs, productivity, or service to the public which exceeds 10%.

PERCENT NO CHANGE PERCENT

COSTS DECREASE INCREASE

Use of sick leave.

Use of overtime/compensatory time.

Staffing requirements.

Overall cost to operate department/unit.

PERCENT NO CHANGE PERCENT

PRODUCTIVITY DECREASE INCREASE

Quality of work by your staff.

Volume of work produced by staff.

Staff completing work on time.

Attendance of staff at meetings.

Responsiveness of your staff to unanticipated

work requests.

PERCENT NO CHANGE PERCENT

SERVICE TO THE PUBLIC DECREASE INCREASE

Service to clients (e.g., inmates, public, other

departments and agencies, Unicor customers, etc).

Provide staff coverage to other department as

needed.

Level of fatigue in department/unit

Ability to fill vacancies or retain employees in

department.

PROVIDE SPECIFIC DATA TO DOCUMENT ANY INCREASES OR DECREASES GREATER THAN 10% IN

PRODUCTIVITY, SERVICE TO THE PUBLIC OR COSTS TO THE AGENCY

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

RECOMMENDED ACTION:

___ DISCONTINUE THE COMPRESSED WORK SCHEDULE

___ CONTINUE THE COMPRESSED WORK SCHEDULE

Institution: Department/Section:

Supervisor’s Name: Signature: Date

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BP-A1109 BUREAU OF PRISONS TELEWORK AGREEMENT FORM

NOV 16

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Part 1: General Information

(Please type or print clearly)

Action Requested: New Change Termination Date of Request

Employee Information

Employee Name Region/Division Office

( ) ( ) ( ) ( )

Work Phone Blackberry Phone Home Phone Cell Phone

Supervisor’s Name

Part 2: Telework Agreement

The following constitutes an agreement on the terms and conditions of the telework arrangement between the employee and the

Bureau of Prisons.

Approved Telework Option/Days

Select one option:

Routine Scheduled Telework Days

(Per Pay Period)

Week 1 Week 2

Monday

Tuesday

Wednesday

Thursday

Friday Saturday

Sunday

Routine Scheduled Days per month: List Days per month (if not authorized to telework at least one day per pay period, but at least one

regularly scheduled and recurring telework day per month):

Situational (Ad Hoc: short period of time, project based, unscheduled or weather related)

Provide examples of approved telework circumstances.

Pdf Prescribed by P3630

Terms of Agreement

1. Telework is not an employee right. The employee volunteers to telework and to adhere to applicable guidelines and DOJ telework

policies. The Department concurs with employee participation and agrees to adhere to applicable guidelines and policies.

2. The employee agrees to participate for a period beginning: and ending: . The terms of

this agreement should be reviewed and updated as necessary, but no less frequently than once every two years.

3. The supervisor and employee agree to the following tour of duty for the telework location.

Start Time Stop Time

4. Employee’s official worksite:

Street Address City, State

5. Employee’s traditional worksite

(if different from the employee’s offi cial

worksite):

Street Address City, State

6. The approved telework locations

are:

Primary telework location:

Street Address City, State

Secondary telework location:

Street Address City, State

Zip Code

Zip Code

Zip Code

Zip Code

Describe in detail the designated work area at the telework locations:

7. Employee has completed the Safety Checklist for Telework Locations. Employee and supervisor have discussed requirements for

an adequate and safe work area and the employee certifies that all approved telework locations meet those requirements.

8. Employee completed telework training on (date).

9. The following equipment has been issued to the employee and documented by the agency:

Equipment Description Issue Date Serial Number BOP Property Tag # Return Date

Computer

Telephone/ Blackberry

Other

Other

Other

10. All timekeeping, leave, performance requirements, and special pay approvals are the same as for the traditional worksite, except if

telework is frequent enough to require change in duty location.

11. Provided the employee is given at least 24 hours advance notice, the employee agrees to allow the safety manager or a designee, to

inspect the telework location during the employee's normal working hours. This is to ensure worksite conformance with these guidelines.

Terms of Agreement

12. The employee must immediately notify the supervisor of any work related accident, injury, or illness occurring at the telework

location and timely submit completed Occupational Injury/Illness Forms, as appropriate.

13. The Government will not be liable for damages to an employee's personal or real property during the course of performance of official

duties or while using Government equipment in the employee's residence, except to the extent the Government is held liable by Federal

Tort Claims Act.

14. The Government will not be responsible for operating costs, home maintenance, or any other incidental costs whatsoever, associated

with the use of the employee's residence. While teleworking, the employee is entitled to reimbursement for authorized expenses incurred

while conducting business for the Government, as provided for by statute and implementing regulations.

15. The employee will apply approved safeguards when teleworking to protect Government/agency records from unauthorized disclosure or

damage. He/she will comply with the Privacy Act requirements per DOJ Order 3011.1A, and the provisions specified

in DOJ Order 2640.2F, Information Technology Security, in order to protect access to DOJ electronic information and computer systems.

16. The employee may voluntarily terminate a telework agreement at any time. Supervisors may remove the employee from a

telework agreement in accordance with BOP and DOJ telework policies, established administrative procedures, and union negotiated

agreements.

17. The employee agrees to limit performance of officially assigned duties to the traditional worksite or to agency-approved telework

locations. Failure to comply with this provision may result in termination of the telework agreement, or appropriate disciplinary action.

18. The employee agrees that he or she may be required to telework outside of his or her normal telework schedule in the case of a

temporary emergency situation (e.g. worksite closure, authorized early dismissal, authorized delayed arrival, declaration of COOP status).

19. The employee certifies that adequate dependent care arrangements are in place, and will not interfere with the employee’s ability to

telework.

Safety Checklist for Telework Locations

The following checklist is designed to help you assess the overall safety of telework locations. Each participant should read the safety

checklist provided below and certify that all telework locations are in compliance with all listed safety criteria.

Safety Feature Yes No

1. Is the space free of indoor air quality hazards such as asbestos and mold?

2. Is the work space equipped with fire, smoke, and carbon monoxide detectors?

3. Are stairways and walkways nonslip and free of obstructions and trip hazards?

4. Is all electrical equipment free of recognized hazards that would cause physical harm?

5. Are all areas free of obstructions to permit visibility and movement?

I hereby agree to the telework Terms of Agreement and certify that my telework location is in compliance with all listed safety criteria.

Employee's Signature: Date:

Part 3: Supervisor’s Review

Approval

Approval with modification (please describe):

Disapproval (state reason):

Supervisor's signature: Date:

Part 4: Regional/Assistant Director’s Review

Approval

Approval with modification (please describe):

Disapproval (state reason):

Regional/Assistant Director’s Signature: Date:

Part 5: Assistant Director, HRMD Review

Approval

Disapproval (state reason):

Assistant Director, Human Resource Management’s Signature: Date:

Distribution of Copies

Original – Human Resources Copy – Employee Copy – Supervisor