ࡱ> M +bjbj== 0WWAl|||||||!!!8!|d"N#))))*0,3LLLLLLL$N QL|5*"*55L5||))7M5555|)|)L55L5l 5)?:C,||)D)# YK !5"C )DM0NCRQ5Q)D5||||SECTION 18.10 TELECOMMUTING APPLICATION Last Update: 9/03 Name: FORMTEXT      Home Location: FORMTEXT      Classification: FORMTEXT      Home Phone: FORMTEXT      Office Phone: FORMTEXT      Supervisor: FORMTEXT      Office Location: FORMTEXT      Miles from Office to Home: FORMTEXT        Briefly describe your current job responsibilities. (Use additional sheets if necessary).  FORMTEXT       Please read each of the following job characteristics and then rate each according to your current job requirements. If there is a high requirement for this aspect of your job, then mark an X in High. If it has little importance, mark an X in the Low column. Job RequirementsHighLowAbility to control and schedule work FORMTEXT       FORMTEXT      Clear and understandable work assignment objectives FORMTEXT       FORMTEXT      Work autonomy FORMTEXT       FORMTEXT      Concentration required FORMTEXT       FORMTEXT      PC or computer terminal work FORMTEXT       FORMTEXT      Amount of face-to-face contact required FORMTEXT       FORMTEXT      Amount of telephone communications required FORMTEXT       FORMTEXT      Amount of in-office reference material required FORMTEXT       FORMTEXT      Amount of data security required FORMTEXT       FORMTEXT       High ratings for items 1 - 5 and low ratings for items 6 - 9 indicate a likelihood that the job is compatible with a telecommuting arrangement. Describe how your current job will be adapted to telecommuting.  FORMTEXT       How will telecommuting assist you in meeting the goals and needs of your work unit and the department, and benefit the State?  FORMTEXT       Considering the nature of your work, would you want to telecommute from home or another office close to your home? HomeYes FORMCHECKBOX No FORMCHECKBOX Another OfficeYes FORMCHECKBOX No FORMCHECKBOX If Yes, Where? FORMTEXT       How often would you want to telecommute? (check only one)  FORMCHECKBOX  (a) About once every 2 weeks  FORMCHECKBOX  (b) About once a week  FORMCHECKBOX  (c) Two days a week  FORMCHECKBOX  (d) Three or four days a week  FORMCHECKBOX  (e) Five days a week  FORMCHECKBOX  (f) Occasionally for special projects What kinds of work would you expect to do while telecommuting? (Check as many as apply and provide approximate percentage of time for each.) Percentage of Time FORMCHECKBOX (a)Writing FORMTEXT       FORMCHECKBOX (b)Word processing FORMTEXT       FORMCHECKBOX (c)Data management/computer programming FORMTEXT       FORMCHECKBOX (d)Reading FORMTEXT       FORMCHECKBOX (e)Talking on the phone FORMTEXT       FORMCHECKBOX (f)Sending/receiving electronic mail FORMTEXT       FORMCHECKBOX (g)Field visits/meetings FORMTEXT       FORMCHECKBOX (h)Planning/organizing FORMTEXT       FORMCHECKBOX (i)Administrative support work FORMTEXT       FORMCHECKBOX (j)Batch work FORMTEXT       FORMCHECKBOX (k)Evaluation/research/analysis FORMTEXT       FORMCHECKBOX (l)Other (please specify)  FORMTEXT       FORMTEXT       Have you ever worked from home on a regular basis?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, briefly describe.  FORMTEXT       If applicable, describe the workspace in your home that you intend to dedicate to performing your work.  FORMTEXT       What equipment would you need to enable you to telecommute? (Check all that apply)  FORMTEXT       NeedCurrently Have(a)Computer/terminal FORMCHECKBOX  FORMCHECKBOX (b)Printer FORMCHECKBOX  FORMCHECKBOX (c)Software FORMCHECKBOX  FORMCHECKBOX (d)Modem FORMCHECKBOX  FORMCHECKBOX (e)Additional phone line FORMCHECKBOX  FORMCHECKBOX (f)Office furniture FORMCHECKBOX  FORMCHECKBOX (g)Fax FORMCHECKBOX  FORMCHECKBOX (h)Photocopier FORMCHECKBOX  FORMCHECKBOX (i)Other (please specify) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  What distractions or obligations might make working at home difficult? What are your plans for handling these?  FORMTEXT        FORMTEXT      Employee s SignatureDate Supervisor's Comments: Please provide your assessment of this employee's ability to telecommute, including the need for supervision and frequent feedback, organization and planning skills, level of self-discipline to complete work and potential problems if telecommuting.  FORMTEXT       Please provide an assessment of how this department and the State will benefit if this employee telecommutes.  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