TELEWORK REQUEST AND APPROVAL FORM

DLA FORM 1864, JUL 2004 PDF (DLA)

1. EMPLOYEE 2. ORGANIZATION 3. JOB TITLE 

4. GRADE AND JOB SERIES 5. PHONE NUMBER 6. Last Performance Evaluation Rating 

7. DESCRIPTION OF WORK TO BE PERFORMED: 

8. DESCRIPTION OF OUTPUTS: 

9. BENEFITS FOR EMPLOYEE AND THE EMPLOYER (CHECK ALL THAT APPLY);

10. EQUIPMENT AND SOFTWARE REQUIRED: 

11. NUMBER OF COMMUTER MILES SAVED PER TELEWORK DAY: 

Page 1 of 2

Improved Productivity

Improved Morale

Incentive to remain with DLA

Environmental Concerns

Improved Job Access

Reduced Commuting Cost

Workspace Availability

Reduced Parking

Promoting DLA as an Employer

Other (Specify below)

9a. Specify Other Benefits: 

12. START DATE 13. END DATE 
d. SELECT SCHEDULE TYPE:

Fixed schedule in accordance with local guidance and/or collective bargaining agreement.

Flexitime in accordance with local guidance and/or collective bargaining agreement.

AWS in accordance with local guidance and/or collective bargaining agreement.

DLA FORM 1864, JUL 2004 Page 2 of 2

14. IF REGULAR AND RECURRING

a. TELEWORK TOUR OF DUTY (e.g., 8:30 A.M. - 5:00 P.M., including a one-half hour lunch period.)

From: To: 

b. Day(s) of the week employee will telework: 

e. ALTERNATE WORK SITE ADDRESS:

15. IF PERIODIC OR INTERMITTENT

a. TELEWORK TOUR OF DUTY (e.g., 8:30 A.M. - 5:00 P.M., including a one-half hour lunch period.)

From: To: 

b. Dates employee will telework: 

d. SELECT SCHEDULE TYPE:

Fixed schedule in accordance with local guidance and/or collective bargaining agreement.

Flexitime in accordance with local guidance and/or collective bargaining agreement.

AWS in accordance with local guidance and/or collective bargaining agreement.

e. ALTERNATIVE WORK SITE ADDRESS:

16. SIGNATURES AND RECOMMENDATION

e. SUPERVISOR'S RECOMMENDATION

Approved Disapproved

17. APPROVAL

a.

Approved Disapproved (Explaining reason below.)

d. REASON FOR DISAPPROVAL: 

b. APPROVING OFFICIAL c. DATE 

a. EMPLOYEE'S SIGNATURE b. DATE 

c. SUPERVISOR'S SIGNATURE d. DATE 

c. Number of Days per Week Telework is Recommended:

12345

c. Number of Days per Week Telework is Recommended:

12345

Number of Days per Week Telework is Recommended:

12345

Number of Days per Week Telework is Authorized:

12345

PRIVACY ACT STATEMENT

AUTHORITY:

PRINCIPAL PURPOSE(S):

ROUTINE USES:

DISCLOSURE:

DLA PRIVACY ACT SYSTEM NOTICE S330.10 APPLIES

Public Law 106-346, Sec. 359, Transportation Appropriations Act, 2001 (Telecommuting).

Information is collected to register individuals as participants in the DLA alternate workplace program; to manage and document the duties of

participants; and to fund, evaluate and report on program activity. The records may be used by Information Technology offices for determining

equipment and software needs; for ensuring appropriate system safeguards are in place, and for managing technological risks and

vulnerabilities.

Information may be disclosed for any of the Routine Uses published by DLA and posted at 

http://www.defenselink.mil/privacy/notices/dla/dla_preamble.html.

Disclosure is voluntary. However, failure to provide the requested information may result in our inability to include you as a participant in the

alternate workplace program.