Date of Request: Proposed Start Date of Remote Work:
Location of Official Work Site:
City: ___________________________ State: _____________________
Note: Official worksite us used to determine pay, reduction in force (RIF) competitive area, travel reimbursement, and
unemployment compensation.
Assignments and Communication: [Use if appropriate. This may include work assignment, clarification related to remote
worksite, agreements related to office communication, checking/responding to voicemail and email and/or contacting the
supervisor]
Component-Specific Remote Work Training [Identify any specific requirements and completion date, if applicable.]
Travel and Relocation Expenses
All costs associated with a move to the new official worksite are the responsibility of the employee. The employee agrees to
waive any rights to moving expenses if directed to return to the regular worksite based on a decline in performance or for
misconduct.
Employee Initials _______
[Insert Component-specific travel policy, as applicable.]
Remote work within the locality pay area
Employees will not be paid for local travel to the agency’s worksite if their official worksite is within the local commuting
area (50-mile radius, as defined in the Joint Travel Regulations (JTR))
Employees will be paid for travel to the agency’s worksite if their official worksite is outside the local commuting area (50-
mile radius, as defined in the JTR).
Employees will be paid for travel from their official worksite for official business travel to locations away from the agency’s
worksite.
Remote work outside the locality pay area:
Employees will be paid for travel from their official worksite for official business travel to the agency’s worksite.
Employees will be paid for travel from their official worksite for official business travel to locations away from the agency’s
worksite.
Sample Remote Work Agreement
Pay Entitlements
All pay entitlements (including locality-based pay) and other government benefits are based on the new official remote worksite
identified above.
Requests for Change of Remote Location
Employees must obtain supervisor’s oral or written approval to work at a location other than the approved alternative remote
worksite prior to making any arrangements and reporting to work (e.g., temporary arrangements).
Requests for permanent changes to alternative remote work location must be made at least 30 calendar days in advance.
Approved requests will require a new Remote Work Agreement and the servicing human resources office will complete a
Standard Form (SF) 50, “Notification of Personnel Action,” documenting the approved alternative worksite location.
Employee Name: Employee Signature:
Date:
Supervisor Action
□ Approve □ Disapprove Date:
Supervisor Signature:
Sample Remote Work Agreement
This is an Agreement made between ______________________ (Employee's Name) and the (Insert
Agency Name), referred to collectively as “the Parties.” Effective ___________________ (month,
day, and year) _______________________ (Employee’s Name) official duty station will change
from _________________ (City, State) to their new official remote worksite, _________________
(City, State). The decision to allow an employee to work remotely is not an employee entitlement,
and the decision is at the discretion of the supervisor and (Agency Name). The Parties sign this
Agreement as acceptance of the terms and conditions as follows:
Policies
The Parties agree to abide by all Agency rules and policies, including human resource policies,
information policies, the intellectual property rights of the Agency, and applicable collective
bargaining agreements.
The employee will be familiar with the following policies and guidelines:
• Remote Work Policy
• Technology & Equipment Policy
• Software Policy
• Public Documents Policy
• Data Security Policy
Travel/Relocation Expenses
All costs associated with a move to the new official worksite are the responsibility of the employee.
The employee agrees to waive any rights to moving expenses if directed to return to the regular
worksite based on a decline in performance or for misconduct.
[Insert Component’s Travel Policy based on within or outside of commuting area]
Remote work within the locality pay area:
• Employee will not be paid for local travel to the agency’s worksite if their official
worksite is within the local commuting area (50-mile radius, as defined in the Joint
Travel Regulations)
• Employee will be paid for travel to the agency’s worksite if their official worksite is
outside the local commuting area (50-mile radius, as defined in the JTR).
• Employee will be paid for travel from their official worksite for official business travel to
locations away from the agency’s worksite.
Remote work outside the locality pay area:
• Employees will be paid for travel from their official worksite for official business travel
to the agency’s worksite.
• Employees will be paid for travel from their official worksite for official business travel
to locations away from the agency’s worksite.
Pay Entitlements
All pay entitlements (including locality-based pay) are based on the new official remote worksite
identified above.
The employee’s salary and government benefits are based on the remote location.
The employee is responsible for reviewing and ensuring the accuracy of their Leave and Earnings
Statement.
Office Closures
Remote employees are expected to work during any regional Federal office closures, delayed
arrivals, and early dismissals. Remote employees must notify their supervisor immediately when
emergencies occur that affect a remote worksite to request leave, excused absence, worksite
relocation, etc.
Requests for Change of Remote Location
Employee must obtain supervisor’s verbal or written approval to work at a location other than the
approved alternative remote worksite prior to making any arrangements and reporting to work (e.g.,
temporary arrangements).
Requests for permanent changes to alternative remote work location must be made at least 30
calendar days in advance. Approved requests will require a new Remote Work Agreement and
the servicing human resources office will complete a Standard Form (SF) 50, “Notification of
Personnel Action,” documenting the approved alternative worksite location.
Termination
The Parties understand that this agreement will be assessed as needed. The agreement is not a
contract of employment, and can be terminated at any time by either the agency or employee
determines that the arrangement no longer meets mission requirements or the needs of the
workgroup, for misconduct, for non-compliance with the terms of the remote work agreement, or
other business-based reasons.
In the event this agreement is terminated, a written notification of cancellation, including
justification for the cancellation must be provided at least 30 calendar days before the effective
date.
Acknowledgements
[Employee name] understands all equipment provided by the Agency is U.S. Government property
and must be managed and disposed of in accordance with Agency policies. If productivity is not
maintained to the supervisor’s expectations, the supervisor of [Employee Name] may have grounds
for disciplinary action and/or discontinuance of this agreement.
[Employee name] understand that he/she is not required to report to the office on a regular and
recurring basis during each pay period. However, the [Employee name] may be directed to report
to the office by the supervisor on an occasional basis, as mission dictates.
The Parties understand and agree that this Agreement will not be executed until and unless the
remote work request referred to herein is approved, in writing, by the employee’s [Insert approval
authority]. If the remote work request is not approved by the [Insert approval authority] then this
Agreement is of no force and effect and is not binding upon either of the Parties.
__________________________________ ___________________
Supervisor’s Signature Date (mm/dd/yyyy)
__________________________________ ___________________
Employee’s Signature Date (mm/dd/yyyy)
Safety Checklist
__________________________________ ___________________
Employee’s Signature Date (mm/dd/yyyy)
Safety Feature X
Yes
No
1. Temperature, ventilation, lighting and noise levels are adequate
for maintaining a home office.
2. Electrical equipment is free of recognized hazards that would
cause harm (frayed, exposed, or loose wires; loose fixtures, bare
conductors; etc.).
3. Electrical system allows for grounding of electrical equipment
(three-pronged receptacles).
4. Office (including doorways is free of obstructions to permit
visibility and movement.
5. File cabinets and storage are arranged so drawers and doors do
not enter into walkways.
6. Phone lines, electrical cords, and surge protectors are secured
under a desk or alongside a baseboard.
7. If material containing asbestos is present, it is in good condition.
8. Office space is free of excessive amount of combustibles, floors
are in good repair, and carpets are well secured.
I verify that this safety checklist is accurate and that my home office is a reasonably safe place
to work. Signature
DoD Remote Worker Agreement Supervisor Checklist
Supervisors must use this checklist to ensure that remote work requirements are met and that
covered employees understand the policies and procedures of the remote work program. A
Remote Worker Agreement is not final until the checklist is complete. After an item is
completed, list the date on the line next to it.
Also, identify any Government equipment/property that will be provided for the remote site
below, as applicable:
Item Yes No
Computer:
Docking Station:
Printer:
Monitor:
Keyboard:
Checklist Item:
1. Remote Guidelines have been explained to the employee and signed by
supervisor and employee (attached).
2. The provisions governing premium pay have been explained to the
employee including that he/she must receive the supervisor’s approval
In advance of working overtime.
3. Performance expectations have been discussed with the employee.
Performance Standards are in place and have been signed
4. Policies and procedures covering classified, secure and privacy data
including PII have been explained to the employee.
5. The provisions governing changes to the terms and conditions of the
remote work agreement have been explained to the employee, including
that they must receive the supervisor’s approval in advance of any
changes to the location of the duty station (i.e., remote work site).
Failure to obtain management approval may result in termination of the
remote work agreement.
6. The employee has been given and signed the Safety Checklist, which
identifies safety and adequacy issues that employees should consider
when working from home (attached).
Item Yes No
Mouse:
Other Item 1:
Other Item 2:
Other Item 3:
Other Item 4:
Remote Worker Guidelines
Applicability. The Remote Work Policy applies to current and future remote workers. A remote
work arrangement may be initiated by an employee for the convenience of the employee or by
the agency.
Duty Station. All pay and travel entitlements are based on the official worksite.
Salary and Benefits. Approving a remote worksite may affect pay, RIF competitive area, travel
reimbursement, and/or unemployment compensation.
Official Worksite. In accordance with 5 CFR 531.605, the official worksite is the location
where the General Schedule employee regularly performs their duties. If the employee is not
scheduled to report to the agency worksite at least twice each biweekly pay period on a regular
and recurring basis (i.e., is a remote worker), the employee’s official worksite for location-based
pay purposes is the alternative work location under the remote work agreement.
Official Duties. The employee will perform only official duties at the official remote worksite.
The employee may not conduct personal business while in official duty status at the remote site.
Time and Attendance. The employee will follow established office procedures for requesting
and obtaining approval of leave. The supervisor must certify biweekly time and attendance for
hours worked at the remote worksite.