Appendix B: Remote Work Agreement

B-1

OSMRE Employee-Initiated Remote Work Agreement

This agreement is voluntarily made between (insert employee’s name) and the (insert Bureau/Office 

name) on (insert month, day, year). (Insert employee’s name) will change their official duty station 

from (insert City, State) to their new official remote worksite, (insert City, State).

By signing this Agreement, I certify that I have read the (insert Bureau/Office Policy name) and will 

comply with the requirements.

I understand all costs associated with a move to the new official worksite are the responsibility of 

the employee.

I understand the decision to allow an employee to work remotely is not an employee entitlement, 

and the decision is at the discretion of the supervisor and (insert Bureau/Office name) management.

I understand all pay entitlements (including locality-based pay) are based on the official 

worksite identified above. I understand certain benefits and state taxes may be affected by 

this locality. I understand that the annual salary, including locality, for my official remote 

worksite is (insert annual salary, including locality).

I understand this action is to fulfill specific business needs of (insert Bureau/Office name). The 

employee or the supervisor may terminate the remote work arrangement at any time if it no longer 

meets the needs of the office, for a decline in performance or productivity, for misconduct, for noncompliance with the terms of the remote work agreement, or for other reasons. For managementinitiated terminations, the employee must receive advanced written notification of the decision to 

terminate the remote work arrangement at least 30 days before the effective date of the 

termination. For employee-initiated terminations, such requests must be made in writing with 

advance notice of at least 30 days.

I understand that I am required to have reliable internet. I further understand that my remote work 

environment must be maintained to the same safety standards as those required for DOI telework 

employees. Specifically, the remote work area must adhere to the same safety checklist items as 

provided in DI Form 3457 (Telework Agreement). Further, I am responsible for informing my 

supervisor of any significant change to the remote work area or workspace.

I understand remote work cannot be used as an alternative for the employee to be the sole source 

of dependent care, including child or elder care, or to conduct personal business during work hours.

I understand that upon entering into a remote work agreement I will no longer have access to my 

former physical workspace. If I am no longer on a remote work agreement I will diligently work with 

management as it relates to spacing. 

I also understand that this agreement will be assessed annually, though it can be reevaluated at any 

time.

With this approved remote work arrangement, I understand my benefits, retirement, etc. could be 
Appendix B: Remote Work Agreement

B-2

impacted. I understand I am responsible for reviewing my Leave and Earnings Statement to ensure 

accuracy of information.

I understand the costs for which my Bureau/Office will be responsible for paying are: (insert the office 

equipment/ services the Bureau/Office will furnish the employee); telephone service through the 

government-issued phone, if applicable; and any required temporary duty travel away from the 

official remote worksite.

I understand all Bureau/Office equipment will be returned to (insert return name) in the event of 

my separation.

 

 

Annual Recertification/Biannual Review of Remote Work Agreement 

Employee Signature Date

First-Level Supervisor Signature Date

OSMRE Information Resources Office Date

AD/RD/Staff Office Head Date

OSMRE Deputy Director Date

Review Date Supervisor Signature Employee Signature