Remote Work Participation Agreement

𝗖𝗨 𝗔𝗻𝘀𝗰𝗵𝘂𝘁𝘇 𝗜𝗻𝘀𝘁𝗿𝘂𝗰𝘁𝗶𝗼𝗻𝘀:

This form only needs to be completed if you are: O A 12-month faculty or staff member who has been assigned an office or has access to a workspace on campus and is requesting to work full/part-time remotely. OR O A 12-month faculty or staff member who lives and works outside of Colorado or the USA. O This form should be submitted only for remote work that is regularly scheduled (e.g. - 1 or more days per week). O This form should not be submitted if your remote work arrangement is not regularly scheduled, is ad hoc, or is on a very occasional basis. Please use this form to submit a new remote work request for your current position. This form does not carry over to another role. A new form will be required if filling out for another role. If you wish to amend an existing agreement, you will need to submit this form again. Student Employees are not required to complete this form.

Please use this form to submit a new remote work request for your current position. This form does not carry over to another role. A new form will be required if filling out for another role. If you wish to amend an existing agreement, you will need to submit this form again. Student Employees are not required to complete this form.

Employee First Name*

Employee Last Name*

Employee Email*

For CU Anschutz Medical Campus email addresses, please use firstname.lastname@cuanschutz.edu

Employee ID Number*

Please enter a CU Anschutz Medical Campus. Employee IDs are 6 digits.

Is this request related to an Americans with Disabilities Act (ADA) accommodation??*

Yes

No

Justification Narrative*

A narrative explaining the reason for remote work and the benefit to the university in agreeing to the arrangement is required.

Effective Date*

Principal School/College/Department*

Select

Department, Division or Work Unit

Select

Is the employee working internationally?*

Select

Remote Work Location - City*

Please note: If the address changes, a new remote work request form must be filled out by the employee.

Remote Work Location Address*

Please note: If the address changes, a new remote work request form must be filled out by the employee.

Remote Work - Zip Code*

Please note: If the address changes, a new remote work request form must be filled out by the employee.

Employee's Remote Work Phone Number*

If the phone number is an international number, please include the country code.

Number of Days Per Week Working Remotely*

Please enter the numerical value and check all boxes below that apply.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Remote Work Hours*

Please indicate the remote work hours that will be worked. Example: Monday and Wednesdays - 8 a.m. to 2 p.m. If variable please select all the days above that apply. If variable days and times, please describe below.

The following University equipment, software and supplies will be used at the remote work location:*

Please note: The University does not provide cell phones, or pay for internet as a result of people working remotely. Any other equipment would be as agreed upon between the employee and their unit.

University equipment, software and supplies will be provided by:*

Please enter the department name. Please note: The University does not provide cell phones, or pay for internet as a result of people working remotely. Any other equipment would be as agreed upon between the employee and their unit.

The following arrangement has been agreed upon for communications, including return and handling telephone calls, including long distance, e-mail and communicating with the regular office:*

Additional Conditions Agreed Upon

Supervisor First Name*

Supervisor Last Name*

Supervisor Email*

For CU Anschutz Medical Campus email addresses, please use firstname.lastname@cuanschutz.edu

Department Approver/Unit Human Resources Business Partner First Name*

Department Approver/Unit Human Resources Business Partner Last Name*

Department Approver/Unit Human Resources Business Partner Email*

For CU Anschutz Medical Campus email addresses, please use firstname.lastname@cuanschutz.edu

Does more than 0.5 of your FTE reside in the School of Medicine?

Select

Remote Work Participation Agreement Acknowledgment

The above information reflects the discussion and agreement with my supervisor. I have read the Alternative Work Schedules and Remote Work Arrangements policy and understand and agree to its conditions. I have also read and understand my school or college policy and understand and agree to its conditions. I further understand that failure to adhere to these conditions may result in termination of the Remote Work agreement or other corrective or disciplinary actions. Please click on the checkbox below to acknowledge this agreement.*

I acknowledge this agreement.

𝗣𝗹𝗲𝗮𝘀𝗲 𝗻𝗼𝘁𝗲: This agreement is subject to re-evaluation by the Supervisor and is subject to review by the Appointing Authority.

𝗣𝗹𝗲𝗮𝘀𝗲 𝗻𝗼𝘁𝗲: It will take approximately 20 minutes to receive a copy of the form. If you do not see the confirmation email in your inbox, please check your junk and clutter folders.