+----------------------------------------------+---------------+-------+
| **Summary Page for Routing and Approvals**   |               |       |
|                                              |               |       |
| **FROM:** Employee                           |               |       |
|                                              |               |       |
| Name: Business Unit:                         |               |       |
|                                              |               |       |
| I Agree To The Terms And Conditions of this  |               |       |
| Agreement:                                   |               |       |
|                                              |               |       |
| Signature of Employee                        |               |       |
+----------------------------------------------+---------------+-------+
|                                              | Signature     | Date  |
+----------------------------------------------+---------------+-------+
| **TO:** Supervisor Endorse application       |               |       |
|                                              |               |       |
| Do not endorse application                   |               |       |
|                                              |               |       |
| Name:                                        |               |       |
|                                              |               |       |
| **Comments:**                                |               |       |
+----------------------------------------------+---------------+-------+
| **TO:** Division/Office Director Endorse     |               |       |
| Application                                  |               |       |
|                                              |               |       |
| Do not endorse application                   |               |       |
|                                              |               |       |
| Name:                                        |               |       |
|                                              |               |       |
| **Comments:**                                |               |       |
+----------------------------------------------+---------------+-------+
| **TO:** AWA Steering Committee Review:       |               |       |
| Endorse Application                          |               |       |
|                                              |               |       |
| NSA Suite 100 Do not endorse application     |               |       |
|                                              |               |       |
| Fax 301-402-0124                             |               |       |
|                                              |               |       |
| **Comments:**                                |               |       |
+----------------------------------------------+---------------+-------+
| **TO:** Approving Official Approved          |               |       |
|                                              |               |       |
| Director, ORS Denied                         |               |       |
|                                              |               |       |
| Dr. Alfred Johnson                           |               |       |
|                                              |               |       |
| 31/4B54                                      |               |       |
|                                              |               |       |
| **Comments:**                                |               |       |
+----------------------------------------------+---------------+-------+
| **TO:** AWA Steering committee - for         |               |       |
| distribution (AWA Steering Committee Use     |               |       |
| Only)                                        |               |       |
|                                              |               |       |
| NSA Suite 100 Effective Date:                |               |       |
|                                              |               |       |
| Fax 301-402-0124                             |               |       |
|                                              |               |       |
| End Date:                                    |               |       |
|                                              |               |       |
| Recorded on Spreadsheet                      |               |       |
+----------------------------------------------+---------------+-------+

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

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

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

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

  --------------------------------- -------------------------------------
  **IC:**                           **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 hr day)

Standard 8.5 hr day

Compressed Work Schedule 5/4 -9 hr days

Compressed Work Schedule 4 -- 10 hr days

Flexible Work Schedule - Gliding Schedule

Other (provide details)      

**Type of telework arrangement requested**

**Core:** Core arrangements are regularly scheduled times or days.

> 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

**Ad hoc/Situational/Episodic** (project-related work, weather related,
liberal leave days)

Note: this 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 **10**

**Tour of duty on telework days?** From To (include meal break and/or
any break in duty hours, if applicable).

**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)?**

     

**Please describe at least two measurable outcomes from a typical
teleworking day?**

     

**I have established my teleworking goals with my supervisor and our
plan to measure my job performance is (daily, weekly, by email, in
person, please be specific)?**

     

**How will you continue to provide optimal customer service while
telecommuting, such as forwarding phone calls, email response, drop in
customers (please identify your customers in answering this question)?**

     

**How will you ensure access to documents needed to continue business
activities on site while you are working from home or at a remote
location?**

**How far in advance would you need to be notified to come in to the
office on a telecommute 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 to home phone (provide home
number\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

Calls will be forwarded to Blackberry/Cell Phone (provide cell number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

I have tested the above procedure and it worked)

**If work phone is not forwarded, I agree to check voice mail messages
every hour.**

> Telework requires high-speed access (broad band) to NIH via VPN.
>
> VPN account is established and has been recently tested. An IT Remote
> Access agreement is in place.

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

**Check the training you have taken or to prepare for a successful
Telework experience**.

[]{.mark}

OPM Telework 101 for Employees, on-line course

> <http://www.telework.gov/courses/index.html>

OPM Telework 101 for Managers, on-line course

> <http://www.telework.gov/courses/index.html>

[]{.mark}

[]{.mark}

**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?      

**Do these documents contain sensitive/personally identifiable
information? (e.g., names, social security numbers, dates of
birth...):** Yes No

**Will you require remote access to sensitive information?** Yes No

If "yes", how will you safeguard this information?      

# 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 (dial up or
                                      broadband)

      Cell phone (number:     )       Locked filing cabinet

      Computer                        Desk

      Second telephone line           Voice mail system

      Dial Up Modem                   Answering machine

      DSL or Cable Modem              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:     )        Internet service (e.g.comcast)

      Cell phone (number:     )       Locked filing cabinet

      Computer                        Desk

      Second telephone line           Voice mail system

      Dial Up Modem                   Answering machine

      DSL or Cable Modem              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 as Yes No

specified at
[www.nih.gov/od/ors/ds/ergonomics](http://www.nih.gov/od/ors/ds/ergonomics)?

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

-   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://www.nih.gov/od/ors/ds/ergonomics/index.html>).

-   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 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.