+----------------------------------------------+---------------+-------+
| **ROUTE SLIP**                               |               |       |
|                                              |               |       |
| New                                          |               |       |
|                                              |               |       |
| Renewal                                      |               |       |
|                                              |               |       |
| **1. FROM:** (Applicant)                     |               |       |
|                                              |               |       |
| I Agree To The Terms And Conditions of this  |               |       |
| Agreement:                                   |               |       |
|                                              |               |       |
| Signature of Employee (required)             |               |       |
+----------------------------------------------+---------------+-------+
| **\***INSTRUCTIONS: [Complete section 1 & 2  | Signature     | Date  |
| of route slip and all pages of               |               |       |
| application.]{.underline} Mail or fax entire |               |       |
| application to the Telework Coordinator      |               |       |
| (section 4.) The application will be         |               |       |
| reviewed by the Telework Coordinator who     |               |       |
| will obtain required approval and signature  |               |       |
| of the approving official and notify         |               |       |
| applicant of final approval.                 |               |       |
+----------------------------------------------+---------------+-------+
| **2. TO:** **Supervisor** **(required)**     |               |       |
| Endorse application                          |               |       |
|                                              |               |       |
| > (1^st^ line supervisor) Do not endorse     |               |       |
| > application                                |               |       |
|                                              |               |       |
| Name:                                        |               |       |
|                                              |               |       |
| Comments:                                    |               |       |
+----------------------------------------------+---------------+-------+
| **3. TO:** **Division/Office Director**      |               |       |
| Endorse Application                          |               |       |
|                                              |               |       |
| (if applicant's supervisor) Do not endorse   |               |       |
| application                                  |               |       |
|                                              |               |       |
| Name:                                        |               |       |
|                                              |               |       |
| Comments:                                    |               |       |
+----------------------------------------------+---------------+-------+
| **4. TO:** **Telework Coordinator Review     |               |       |
| (required)**                                 |               |       |
|                                              |               |       |
| Send application to: Reviewed                |               |       |
|                                              |               |       |
| Joanne Aarons                                |               |       |
|                                              |               |       |
| NSA Suite 100/MSC 3360 or Fax 301-402-0124   |               |       |
|                                              |               |       |
| Comments:                                    |               |       |
+----------------------------------------------+---------------+-------+
| **5. TO:** **Approving Official (required)** |               |       |
| Approved                                     |               |       |
|                                              |               |       |
| Executive Officer ORS/ORF Denied             |               |       |
|                                              |               |       |
| Name:                                        |               |       |
|                                              |               |       |
| Comments:                                    |               |       |
+----------------------------------------------+---------------+-------+
| **FOR DECISION MEMO ONLY:**                  |               |       |
|                                              |               |       |
| **6. TO:** Approving Official Approved       |               |       |
|                                              |               |       |
| Director, ORS Denied                         |               |       |
|                                              |               |       |
| Dr. Alfred Johnson                           |               |       |
|                                              |               |       |
| Comments:                                    |               |       |
+----------------------------------------------+---------------+-------+
| **7.** **TO:** WMPB                          |               |       |
|                                              |               |       |
| NSA Suite 100 Effective Date:                |               |       |
|                                              |               |       |
| Fax 301-402-0124                             |               |       |
|                                              |               |       |
| End Date:                                    |               |       |
|                                              |               |       |
| Recorded on Spreadsheet                      |               |       |
+----------------------------------------------+---------------+-------+

  -----------------------------------------------------------------------
  **Date:**

  -----------------------------------------------------------------------

  --------------------------------- -------------------------- ------------
  **Name:**                         **Job Title:**             **Grade:**
                                                                    

  --------------------------------- -------------------------- ------------

  --------------------------------- -------------------------------------
  **Job Series:**                   **Division:**      

  --------------------------------- -------------------------------------

  -----------------------------------------------------------------------
  **Building/Room Number:**      

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **Work Phone:**      

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **Work Fax:**      

  -----------------------------------------------------------------------

  --------------------------------- -------------------------------------
  **Home Phone :**                  **Home Fax (if applicable):**      

  --------------------------------- -------------------------------------

  -----------------------------------------------------------------------
  **Home Address:**      

  -----------------------------------------------------------------------

**Identify your current work schedule** (AWS refers to all alternatives
to the standard 8.5 hour day)

Standard 8.5 hr day

AWS-Compressed Work Schedule: 5/4 -9 hr days

AWS-Compressed Work Schedule: 4/10 hr days

Flexible Work Schedule - Gliding Schedule

Other (provide details)      

**Type of telework arrangement requested**

**Core without AWS:** Core arrangements are regularly scheduled times or
days. [Include work schedules (AWS and telework) of all Branch or
Division employees as an attachment to this application.]{.underline}

> Identify number of telework hours per day on list below

[1^st^ Week of Pay Period]{.underline} [2^nd^ Week of Pay
Period]{.underline}

**Monday** 0 **Monday** 0

> **Tuesday** 0 **Tuesday** 0
>
> **Wednesday** 0 **Wednesday** 0
>
> **Thursday** 0 **Thursday** 0
>
> **Friday** 0 **Friday** 0

**Core with AWS:** Insert "day off" on non-work day(s).

> *Note:* Core with AWS requires approval of Director, ORS. [Include
> work schedules (AWS and telework) of all Branch or Division employees
> as an attachment to this application]{.underline}.
>
> Identify number of telework hours per day [and]{.underline} use the
> letters: "AWS" to identify AWS day on list below

[1^st^ Week of Pay Period]{.underline} [2^nd^ Week of Pay
Period]{.underline}

**Monday** 0 **Monday** 0

> **Tuesday** 0 **Tuesday** 0
>
> **Wednesday** 0 **Wednesday** 0
>
> **Thursday** 0 **Thursday** 0
>
> **Friday** 0 **Friday** 0

**Ad hoc:** (non-regularly scheduled telework day: e.g. project-related
work, weather related, liberal leave days)

Note: Requires employee test remote access 1X per month to keep the
account active.

Maximum number of days per month

-or-

Maximum number of days per quarter

**Medical:** Include a note from physician and/or medical care provider
which specifies how many hours per day you may work and duration.

**Start Date:**

**End Date:**

**No. of hours per week:**

**Pandemic Flu only:**

*Note*: Requires employee test remote access at least 1X per month to
keep account active.

**What are your tour of duty hours on telework days?**

From To (include meal break and/or any break in duty hours, if
applicable).

[]{.mark}

**Are you listed as an Essential Employee for emergency situations?**

Yes No

**Where will your telework site be located?**

Home

GSA Telework Center (specify which)      

**What job tasks will you perform when you are telecommuting (be
specific)?**

**How will you continue to provide optimal customer service while
telecommuting (please identify your customers in answering this
question)?**

**How far in advance would you need to be notified to come in to the
office on a telework day?**

1-2 hours (usual)

3-4 hours based on distance

More than 8 hours based on medical or special circumstances

**Please explain special circumstances:**      

**What methods of communication will you use when you are telecommuting?
(check ALL that apply)**

> Phone Fax
>
> E-mail Pager/Blackberry
>
> Voice mail Other:      

**How will calls to your office desk phone be handled on your
telecommute day(s)?**

> Calls will be forwarded by Call Forward (SDN) or Ultra Call Forwarding
> (recommended)
>
> to home phone (provide home number\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)
>
> to Blackberry/Cell Phone (provide cell number
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

I have tested the above procedure and it worked)

**Indicate that you have completed the following internet access
requirements**

> Hi-speed internet access is available (Dial-up may NOT be used).
>
> VPN account is established and has been recently tested. Information
> about VPN:
> <http://datacenter.cit.nih.gov/interface/interface231/ask.vpn.html>

**If you have dependent care responsibilities, describe the dependent
care arrangements planned for your telework day(s)**      

**Telework training is listed below and is required before beginning
telework. Please check completed training.**

Online Telework Training for NIH Employees and Managers (printable
certificate)

> <http://hr.od.nih.gov/telework/training/>

***Optional***: OPM Telework 101 for Employees / Supervisors, on-line
course

> <http://www.telework.gov/tools_and_resources/training/employees/index.aspx>

**Will you be taking documents out of the office in order to telework?**
Yes No

> If "yes", what types of documents (give examples)?      
>
> What steps will you take to safeguard these documents?      

**I agree that documents and electronic files containing sensitive and
Personally Identifiable Information (PII) (e.g., names, social security
numbers, dates of birth...) will not be transported or stored in a
non-government provided computer:**

Agree Disagree

**Property information:**

# Personal Property Provided by Employee: 

Listed below are some examples of property that may be furnished by the
employee. These are only examples; please add as many other items as fit
the particular circumstance (note: file cabinets must be able to be
locked). The employee is responsible for the maintenance and repair of
all employee-owned property.

  --- ------------------------------- ------------------------------------
      Telephone (number:     )        Internet service (hi-speed or
                                      broadband)

      Cell phone (number:     )       Locked filing cabinet

      Computer                        Desk

      Second telephone line           Voice mail system

                                      Answering machine

                                      Other (list):      
  --- ------------------------------- ------------------------------------

# 

# 

# Property Provided by Employer:

Listed below are similar examples of employer property that may be
provided to employee as part of the telework arrangement. As set forth
in the accompanying Agreement, the employee is required to promptly
return all employer property to employer upon the termination of the
telework arrangement.

  --- ------------------------------- ------------------------------------
      Telephone (number:     )        

      Cell phone (number:     )       Locked filing cabinet

      Computer                        Desk

      Second telephone line           Voice mail system

                                      Answering machine

                                      Blackberry (number:     )

      Other (list):                   
  --- ------------------------------- ------------------------------------

# 

­­­­­­­­­­­­­­­­­­­­­­­

Office Evaluation information:

Complete for home offices only. Do not complete if using GSA Telework
Center.

Employee has designated the following location as employee's home work
area:

  -----------------------------------------------------------------------
       

  -----------------------------------------------------------------------

(Please specify room or area of residence)

##### A. Work Station Setup

1.  If in basement, will there be a problem with moisture? Yes No N/A

2.  Separate from major family activity area? Yes No N/A

3.  Secure from pets and family members? Yes No N/A

4.  Background or distracting noise is minimal? Yes No

5.  (television, other persons, outside traffic)

6.  Equipment not easily viewed from outside/external areas? Yes No

7.  Office furniture and equipment ergonomically correct Yes No

http://dohs.ors.od.nih.gov/ergonomics_home.htm

8.  Lighting: Directed behind or to the side of line of vision, Yes No

not in front or above it?

9.  Storage: 2 or 4 drawer file drawers needed? Yes No

10. Supplies/resources close to desk? Yes No

11. Does home office comply with lease/association agreement? Yes No N/A

#### B. Safety

> 1\. Safe exit path from work area? (recommended width = 36") Yes No

2.  Evacuation plans established? Yes No

3.  Smoke detector/alarm present and functional? Yes No

4\. Fire extinguisher near work area? Yes No

5\. First aid supplies adequate? Yes No

6\. Extension/power cords secured and in safe condition? Yes No

7.  Electrical outlets not overloaded? Yes No

8.  No tripping hazards with electrical cords, loose rugs or carpet? Yes
    No

9.  Equipment out of direct sunlight and away from heaters? Yes No

10. Air quality/ventilation adequate? Yes No

11. Uncluttered work environment (amount of paper at reasonable levels)?
    Yes No

12\. Overhead shelves or cabinets not in hazardous locations? Yes No

> 13\. Property Insurance? Yes No
>
> Homeowners
>
> Renters
>
> Liability
>
> 14\. To the best of your knowledge, is the space free of material Yes
> No
>
> containing asbestos?
>
> 15\. A drinkable water supply available? Yes No
>
> 16\. Lavatory available with hot and cold running water? Yes No
>
> 17\. All stairs with four or more steps equipped with hand rails? Yes
> No N/A

##### C. Security

1.  Locks on office door or file cabinet drawers? Yes No N/A

2\. Power surge protection in use? Yes No N/A

> 3\. Protective or secure storage for floppy disks? Yes No N/A
>
> 4\. Privacy for confidential phone conversations? Yes No N/A

**Additional Comments/Suggestions:**      

# 

# Telework Terms and Conditions (NIH revision is pending, May 2008)

-   I agree to perform services for the NIH as a teleworker and
    understand that teleworking is a work alternative that must be
    requested and approved by my manager prior to beginning to telework.
    The telework arrangement may be modified or terminated by my manager
    at any time when, in his/her judgment, it adversely affects service
    to customers or the operation of the Agency.

-   I agree that my duties, obligations, responsibilities, and
    conditions of employment with the NIH remain unchanged, and that my
    salary and benefits remain unchanged and are not affected by
    telework.

-   I agree that my work schedule, overtime compensation (if any),
    leave, and other terms and conditions of employment will conform to
    the current collective bargaining agreement or personnel policy as
    applicable, and meet the terms agreed upon with my manager.

-   I agree to develop an effective communications strategy with my
    supervisor and work group including required meetings held at the
    NIH and will follow that approved strategy throughout my telework
    schedule.

-   I agree that if applicable, I will establish dependent care
    arrangements during agreed upon work hours.

-   I agree to designate a remote workspace, subject to manager
    approval, that is free from safety hazards and meets Agency
    ergonomic standards as defined on the NIH ergonomics website and
    http://dohs.ors.od.nih.gov/ergonomics_home.htm

-   I will protect the remote worksite from hazards and danger that
    could affect the equipment and me.

-   I understand that participation is not an entitlement and that it
    may be terminated by me or my manager at any time.

-   I agree to restrict use of any NIH provided equipment, software,
    data, and supplies which are located at my remote worksite to the
    sole use of conducting NIH business.

-   I agree to return to the NIH any telework equipment, software, data,
    and supplies which were supplied by the NIH upon my termination of
    telework or termination of employment.

-   In the event of equipment malfunctions, I agree to notify my
    supervisor immediately. I understand that if a malfunction precludes
    me from working from my remote location, then I may be assigned
    other work or be asked to report to the primary office worksite.

-   I understand that my remote worksite is considered an extension of
    the NIH primary worksite, and if I am injured in the course of
    actually performing official duties at the telework office during
    the agreed upon work hours, I am governed by the provisions of the
    Federal Employees' Compensation Act. I understand that attending to
    personal comfort needs is not considered official duties. If I have
    a job related accident during my telecommuting hours I will report
    it to my supervisor immediately.

-   Provided I am given 24 hours notice, I agree that the NIH may make
    on-site visits to my remote worksite during normally scheduled work
    hours, to investigate the condition and area related to any workers'
    compensation claim that occurred at the telework site.

-   I agree to be liable for injuries to third parties and/or household
    members that occur at my remote worksite, and to indemnify and hold
    the NIH harmless regarding any such injuries.

-   I agree to be responsible for the maintenance and repair of all my
    personal property, and I understand I should have appropriate
    insurance coverage.

-   I agree that all products, documents, reports, and data created as a
    result of my work related activities are owned by the NIH, and will
    be properly secured and returned to the NIH as requested.

-   I acknowledge that I have been supplied with and have read the NIH
    telework policy and will adhere to all other applicable policies and
    laws.

-   I agree that I have read and will comply with the NIH technology
    guidelines on use of agency and employee equipment for the telework
    arrangements.

-   I understand that NIH follows the OPM guidelines for emergency
    closings. Specifically, in the event of an emergency dismissal or
    shutdown, teleworking employees may be required to continue to work
    at their alternative worksites.

-   I understand that the information supplied by me and contained in
    this Telework Agreement and additional information, inquiries, or
    surveys may be used for data collection and evaluation of the NIH
    Telework Program.

Agree Disagree