IDOC Telecommuting Application

IDOC TELECOMMUTING APPLICATION 1 OF 3
October 2021
Idaho Department of Correction
Protecting the public, our staff and those within our custody and supervision.
BRAD LITTLE JOSH TEWALT Governor Director
IDOC TELECOMMUTING APPLICATION
Title:
] drop down
A.Employee Information
Employee Name:
Office Location: drop down
Supervisor:
Division:
Title:
B.Telecommute Request Information
1.Type of telecommute requested:
Regular and/or reoccurring schedule Periodic and/or intermittent
Part of a Reasonable Accommodation Out of state telecommute request
2.How often are you requesting permission to telecommute?
1 day per week 2 days per week 3 days per week Occasionally
3. Address of alternate work location:
4.Reason for request:
C. Appropriateness Assessment
Please read each of the following job characteristics and then rate each according to your current job
requirements. To perform your job, if there is a High requirement, Low requirement, or No requirement for
the indicated category, please mark an X in the appropriate column.
Job Requirements High Low None
Ability to control and schedule work
Clear and understandable work assignment objectives
Ability to work autonomously
Requirement to concentrate on work
Amount of computer work Clear understanding of computer security requirements
Amount of face-to-face contact
Amount of telephone communications Amount of in-office reference material needed
Amount of generally sensitive material / data
IDOC TELECOMMUTING APPLICATION 2 OF 3
October 2021
Amount of HIPAA material work requirement
(Health Insurance Portability and Accountability Act which requires employers to physically separate and safeguard employees’
“protected health information” received from a group health plan) Amount of tax information or protected personally identifiable information (PPI)
Supervisory or training responsibilities
D. Telecommute Work Plan Proposal
1.Briefly describe the work that you will complete while telecommuting – for example, 20%
email, 30% data management, 25% phone consultations, etc.
2.Briefly describe the telecommuting location and workspace, including necessary
equipment. Please note, IDOC may not be responsible for providing telecommute
equipment.
3.Briefly describe how telecommuting will meet the goals of your work unit and the needs of
the State.
4.Supervisor comments (indicate agreement/disagreement with the request):
_________________________________
Supervisor Signature
________________________________
Employee Signature
Date ________________ Date ________________
IDOC TELECOMMUTING APPLICATION 3 OF 3
October 2021
E. Agency Determination
Approved Denied *If denied, please provide justification.
Chief Approving the Request
Deputy Director Approving the Request
**************************************************************************
*Additional Authorization Required for Out of State Telecommuting:
DHR Representative Approving
DFM Representative Approving
SCO Representative Approving
*This completed form needs to be submitted to the IDOC Human Resources Office,
along with a completed IDOC Telecommuting Agreement if the application has been
approved.
Date:
Date:
Date:
Date:
Date:
(Print Name)
(Signature)
(Print Name)
(Signature)
(Print Name)
(Signature)
(Print Name)
(Signature)
(Print Name)
(Signature)
_________________________
______________________
_____________________
_____________________
_____________________