Sample Telework Assignment

Here is a Sample Telecommuter Assignment form developed by, an initiative of, that has been fostering public/private partnerships to find solutions to its region’s transportation issues for over 18 years.

A Teleworker’s Assignment form is completed to define the specifics of teleworking such as frequency, type of work to be completed, the number of times the employee should communicate with the office, etc.  The Assignment is completed by the teleworker and the telemanager.

Teleworker Assignment

Teleworking, or working from another location such as home or an office close to home, is an assignment that the company may choose to make available to some employees when a mutually beneficial situation exists.

Teleworking is not an employee benefit, but rather an alternative method of meeting the needs of the company.  Employees do not have a “right” to telework.  The arrangement can be terminated by either the employee or the company at any time.

Conditions for teleworking agreed upon by the teleworker and his/her supervisor:

1.    The employee agrees to work at the following location: _______________________________________________________________________

2.    The employee will telework ___________days per week.

3.    The employee’s work hours will be from _____a.m. to ______p.m.

4.    The following are the assignments to be worked on by the employee at the remote location, with expected delivery dates:

5.    The following equipment will be used by the employee at the remote location:

6.    The employee agrees to call the central office to get his/her messages at least ________ times per day.

7.    The employee agrees to get all supplies needed for teleworking from the company office.  Reimbursement for out-of-pocket expenses for supplies will need prior supervisory approval.

8.    Additional conditions agreed upon by the telemanager and teleworker are as follows:

I have reviewed the teleworker’s assignment with _________________________prior to his/her participation in the company’s teleworking program.

Date                                                                                Supervisor Name

The above material has been discussed with me.

Date                                                                                Employee Name


Disclaimer: This document is offered as a conceptual sample. Your own document should reflect your company’s policies as well as local, state, and federal regulations. Be sure to consult an attorney familiar with employment law before using any such document.

Sample Telework / Telecommuting Policy: This sets forth a company’s overall policies toward telework.

Sample Telework / Telecommuting Agreement: This documents the understanding between the company and the teleworker or telecommuter.

If you’re looking for samples of documents that employees would use to suggest, request, or justify telecommuting, visit our Individuals: How to Pitch Your Boss on Telework pages.

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