southern illinois university carbondale remote work … · 2020. 10. 28. · send completed form...

Reasons for Request: Reasons for request to enter into a remote work arrangement 1 full-time or Date: Date: Date: Approved Denied Date: Employee will work away from the office Alternate Location #2 (if applicable) Department will Provide 2 Alternate Location #1 part-time Address Phone Schedule of Work: Please attach a schedule of when the employee will be working remote to campus and when the employee will be reporting to his/her work site. Equipment and Supplies Needed for working remote to campus: Items Employee will Provide 1 If the Employee is requesting to work remote to campus for a medical reason, including but not limited to COVID 19, he/she should submit medical documentation to Human Resources only. For employees seeking an accommodation under the ADA, please see https://ada.siu.edu/ 2 Removals of university owned equipment must be documented with a properly completed Equipment Loan Form, please see https://eforms.siu.edu/siuforms/info/acs0302.php Denial Reason: Human Resources Representatives' Signature: Employee Title: Director/Dean Title: Employee Name: Employee AIS#: Director/Dean Name: Department: This arrangement is effective through SOUTHERN ILLINOIS UNIVERSITY CARBONDALE REMOTE WORK AGREEMENT hro4000 Employee Signature: Director/Dean Signature: Vice Chancellor Signature: Must Mark One List of Duties: Please attach a list of the duties to be performed (list all duties that the employee is expected to perform/complete during the duration of the Remote Work Agreement). If the employee is working exclusively from home, the job description should be attached as all duties will be performed remote to campus. By signing this Agreement, Employee acknowledges that he/she has read, understands, and agrees to the Remote Work Guidelines. Employee further agrees to adhere to the all guidelines outlined in the Remote Work Guidelines. Employee understands that he/she remains obligated to comply with all federal, state, and university laws, rules, policies, procedures, and/or instructions. Employee agrees to ensure security safeguards and policies at the same level as in the regular office in order to protect such information from unauthorized disclosure, loss, or damage. Approval to work remotely may be revoked by the university at any time. Required Signatures: Send completed form and documents to: [email protected]

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Reasons for Request: Reasons for request to enter into a remote work arrangement 1

full-time or

Date:

Date:

Date:

Approved Denied

Date:

Employee will work away from the office

Alternate Location #2 (if applicable)

Department will Provide 2

Alternate Location #1part-time

Address

Phone

Schedule of Work: Please attach a schedule of when the employee will be working remote to campus and when the employee will be reporting to his/her work site.

Equipment and Supplies Needed for working remote to campus: Items Employee will Provide

1 If the Employee is requesting to work remote to campus for a medical reason, including but not limited to COVID 19, he/she should

submit medical documentation to Human Resources only. For employees seeking an accommodation under the ADA, please see https://ada.siu.edu/2 Removals of university owned equipment must be documented with a properly completed Equipment Loan Form, please see https://eforms.siu.edu/siuforms/info/acs0302.php

Denial Reason:

Human ResourcesRepresentatives' Signature:

Employee Title:

Director/Dean Title:

Employee Name:Employee AIS#:

Director/Dean Name:

Department:This arrangement is effective through

SOUTHERN ILLINOIS UNIVERSITY CARBONDALE REMOTE WORK AGREEMENT

hro4000

Employee Signature:

Director/Dean Signature:

Vice Chancellor Signature:

Must Mark One

List of Duties: Please attach a list of the duties to be performed (list all duties that the employee is expected to perform/complete during the duration of the Remote Work Agreement). If the employee is working exclusively from home, the job description should be attached as all duties will be performed remote to campus. By signing this Agreement, Employee acknowledges that he/she has read, understands, and agrees to the Remote Work Guidelines. Employee further agrees to adhere to the all guidelines outlined in the Remote Work Guidelines. Employee understands that he/she remains obligated to comply with all federal, state, and university laws, rules, policies, procedures, and/or instructions. Employee agrees to ensure security safeguards and policies at the same level as in the regular office in order to protect such information from unauthorized disclosure, loss, or damage.Approval to work remotely may be revoked by the university at any time.

Required Signatures:

Send completed form and documents to: [email protected]

SIU850130865Line

Blank Page

Dept_School_Unit: Dir_DeanTitle: EmployeeTitle: Effective_FromDate: Dir_DeanName: Alt_Location_2_Phone: Alt_Location_1_Address: Alt_Location_2_Address: Full_or_Part: OffAlt_Location_1_Phone: Items_1: Items_2: Items_3: Items_4: Items_5: Items_6: Item1: OffItem2: OffItem3: OffItem4: OffItem5: OffItem6: OffReasons_for_Request: Dir_Sig_Date: Emp_Sig_Date: Denail_Reason: VC_Sig_Date: HR_Sig_Date: Clear_Form: Approve_Deny: OffPrint_Form: Submit_Form: Effective_ToDate: EmployeeName: EmployeeAISNum: