Di 3457 Telework Agreement Form – Fill Out and Use This PDF

U.S. Department of the Interior	DI-3457
Telework Agreement	December 2019

TELEWORK AGREEMENT

This form should only be used by DOI Employees who have migrated to Microsoft Office 365

Instruction

Instruction: The following constitutes the terms and conditions required by the Department of the Interior to establish the necessary assignments, requirements, procedures, and signatures for teleworking. Please fill out all of the required fields below.

Privacy Act Statement

Privacy Act Statement

The information requested is authorized under the Telework Enhancement Act of 2010, Public Law 111-292, 5 U.S.C. Part III, Subpart E, Chapter 65, for the purpose of determining employee eligibility for participation in the Department of the Interior (DOI) telework program. The information will be used to manage employee telework participation; determine equipment needs; and ensure applicable statutory, regulatory and policy requirements are met. Information may be disclosed to DOI officials to facilitate compliance with telework requirements, to the Office of Personnel Management to report employee telework participation and status of program implementation, or to other organizations as authorized under the Privacy Act or outlined in the routine uses in OPM/GOVT-1, General Personnel Records, 77 FR 73694 (December 11, 2012), which may be viewed athttps://www.doi.gov/privacy/sorn.

Providing information is voluntary; however, failure to provide the requested information may result in employee ineligibility to participate in the telework program.

Telework Agreement Terms

I certify that I:

___will adhere to the requirements of the Departmental Telework Policy and any applicable Bureau/Office supplemental procedures regarding telework. https://www.doi.gov/sites/doi.gov/files/uploads/doi_telework_terms_and_agreement.pdf

___have completed the required telework training in DOI Talent or equivalent Bureau telework training. (https://doitalent.ibc.doi.gov/mod/scorm/view.php?id=6187)

___understand that I will be required to telework when my official worksite is closed due to an inclement weather event or other emergency (e.g., building fire) unless there are extenuating circumstances as determined by my supervisor. I must be prepared to telework when a weather or emergency event is forecasted or anticipated (e.g., a major snowstorm is predicted) by bringing home the necessary equipment and work files.

Employee Information

First Name

Last Name

Bureau/Office

Please consult this link to fill out the Sub- Bureau information https://www.doi.gov/sites/doi.gov/files/uploads/doi-sub-bureau-list.pdf

Sub-Bureau

Title

Pay Plan and Grade

Job Series

Supervisor Name and Title

Supervisor Email

Requested Telework Arrangement (Please select only one)

Core - A telework arrangement in which eligible employees telework from an approved alternative worksite on a recurring scheduled basis—i.e., fixed day(s) per week or pay period.

Situational - A telework arrangement in which eligible employees telework without a set schedule (e.., telework as a result of inclement weather, a personal appointment, or a special work assignment). An employee with an approved situational telework arrangement must obtain advance approval from his or her supervisor to telework on a particularday(s).

Continuity of Operations Personnel Designation (Please check the box below if you are designated a member of the COOP Community)

I have been designated as a member of the DOI Continuity of Operations Plan (COOP) and agree to follow the procedures established for reporting for duty when a COOP plan is activated. I understand that during any period that my Bureau/Office is operating in a COOP status, the COOP plan will supersede the Departmental telework policy.

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U.S. Department of the Interior	DI-3457
Telework Agreement	December 2019

Designated Core Telework Schedule

The fields below are required only if you are requesting a core telework arrangement. Please indicate the day(s) of your core telework schedule.

Core Schedule Days of Work

Pay Period Week 1

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Pay Period Week 2

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Concurring Management Official Name andTitle

Concurring Management Official Email

Telework Location

Telework Location					Telework City
				Residence	Telework State/U.S. Territory
				Telework Center	Telework Zip Code
				Other_______________________	Telework Phone

Telework Site Safety Checklist

The following checklist is designed to assess the overall safety of the telework site. Please read and complete this self-certification safety checklist. NOTE: Employees are responsible for informing their supervisor of any significant change to the telework site work area or space. Safe work guidelines can be found at: http://www.osha.gov/SLTC/etools/computerworkstations/index.html. If this link is unavailable, please contact your servicing Human Resource Office for the latest guidance.

If I cannot answer yes to the questions below, please upgrade the telework space until you can certify the site is safe.

Please answer “Yes”, “No”, or “Not Applicable (NA)” when responding to the questions below:

1.Is the workspace free of asbestos-containing materials? _______

2.If asbestos-containing material is present, is it undamaged and in good condition? _______

3.To the extent it can be determined, is the work area free of indoor air quality problems? _______

4.Is the space free of noise hazards? _______

5.Are temperature, noise levels, and lighting adequate for your normal level of job performance? _______

6.Is all electrical equipment free of recognized hazards that would cause physical harm (e.g., frayed wires, bareconductors,

loose wires, flexible wires running through walls or doorways, exposed wires fixed to the ceiling, missing ground prongs on plugs, etc.)? _______

7.Will the building’s electrical system permit the grounding of electrical equipment? _______

8.Are file cabinets and storage closets arranged so drawers and doors do not open into hallways or exitways? _______

9.Are the phone lines, electrical cords, and surge protectors secured under a desk or alongside abaseboard? _______

10.Is there a smoke detector in or near the work area? _______

11.Is adequate ventilation present for the desired occupancy? _______

12.Are the rungs and legs of chairs sturdy? _______

13.Is the office space neat, clean, and free of excessive amounts of combustibles? _______

I certify that the "Work-At-Home Telework Safety Checklist" is accurate and my telework location is a reasonably safe place to work. Yes

Telework Location Description

Briefly describe the area (e.g. home office) where you will be teleworking.

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U.S. Department of the Interior	DI-3457
Telework Agreement	December 2019

Employee Signature

By signing this form, I certify that the information I have entered is accurate. Once I sign this form, I will email my supervisor the completed telework agreement form. Per Departmental policy, supervisors and concurring management officials (if applicable), should strive to complete the telework agreement form within ten (10) business days of receipt

Employee's Signature/Date

Review of DI-3457 Telework Agreement Form by Approving Official(s)

After you have reviewed the requested above telework agreement details, please indicate your decision on the requested telework agreement by selecting “Approved” or “Denied” below:

Supervisor Review
Approved	Denied

Concurring Management Official Review (Required for Core Telework Agreements Only)

Approved

Denied

If the agreement is denied, please explain your rationale or identify the corrections needed for supervisory approval. Denials should be based on the requirements of the Telework Enhancement Act, the DOI Telework policy, applicable collective bargaining agreements, and the business and operational needs of the office. Please ensure the employee, approving official(s), and bureau telework coordinator receive a copy of this signed document.

Reason for Denial:

By signing this form, I certify I have reviewed the current telework agreement and that my determination on the requested telework arrangement is based on the employee’s position, organizational needs, and the employee’s demonstrated characteristics indicating his or her ability to effectively work away from the official worksite. If the employee is requesting core telework, I understand the concurring management official must also review and approve the telework agreement form.

I acknowledge that my approval (or disapproval) of this form supersedes all other previous versions of the employee’s telework agreement form (DI-3457).

If I later determine that this telework arrangement is no longer in the best interest of the Agency, I may terminate this agreement.

Supervisor's Signature/Date

Concurring Management Official Signature/Date

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