Working from Home Agreement

APPLICATIONEmployee details To be completed by the employee requesting to work from home

Name of employee: Date of request:

Position: School/Section:

Home Address:Designated home based work environment: (specify work area in the home e.g. Study)Supporting documentsThe following may be required for this Working from Home Agreement to be reviewed:WHAT HOWComplete the Home-based Assessment Checklist.

The employee completes and attaches the Home-Based Work Assessment Checklist

Determine tasks, and supervision, training and equipment required to safely work from home.

The employee and supervisor complete the Work Arrangements section (included in this agreement document)

If applicable, the employee attaches any extra risk assessment documentation, refer Project and Task Risk Management Procedure

Outline schedules, contact and reporting arrangements.

The employee and manager/supervisor complete the Communication Arrangements section (included in this agreement document)

Determine who/what needs to be notified

The manager/supervisor completes the Notification Requirements section (included in this agreement document)

APPROVALManager / Supervisor Approval To be completed by the employee’s Manager/SupervisorIs the employee approved to work from home?

Yes No - Discuss the reason(s) why with the employee

Working From Home Arrangement - Start Date End date: Maximum term 3 years

Routine WHS inspection of home office

To be conducted by the employee every:(Specify frequency; e.g. 6

months).

Manager / Supervisor

NameSignature Date

Employee declaration

I, _______________________________ (name of employee), agree that all information provided in this agreement is true and accurate in providing a workplace that is safe and without risk to my health. I agree to comply with all requirements in this agreement and in the Working From Home Minimum Standard, as well as all relevant University policies and procedures.

Employee’s signature Date:

ASSESSMENT

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Working from Home Agreement

PART A – WORK ARRANGEMENTS: Proposed Tasks, Supervision and TrainingTo be completed by the employee’s Manager/Supervisor with the employeeClearly outline the work / tasks to be performed by the employee in a home based work environment

If it is proposed the employee complete work from home other than general office / computer work, then a risk assessment is required in accordance with the University’s WHS Project and Task Risk Management Minimum Standard.Is a Risk Assessment for any of the above tasks required? Yes No

Outline the supervision provisions for the above work?

Identify any specific training, instruction, information, experience, etc. the employee is required to possess to safely carry out these tasks from home including how the employee will report any incident:

Outline any work expectations, and the way in which performance will be monitored and assessed (e.g. measurement of output)

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Working from Home Agreement

PART B – EMPLOYEE ASSESSMENT: Workers Compensation and RehabilitationTo be completed by the employee (and Workers’ Compensation staff if applicable)

Medical Result Action to be taken / CommentsDoes the employee have a pre-existing injury that may be aggravated by performing University work tasks from home? Yes No

If “yes”, discuss and answer questions below with University Workers’ Compensation staff prior to proceeding.If “no”, skip to Part C. below.

Has the employee seen a health / medical professional about this issue?

Yes N/A No

Does the employee have any recommendations from a health / medical professional?

Yes N/A No

University Workers Compensation approval (if applicable) Result Action to be taken / Comments

Is the employee approved to work from home?

(The suitability of the home based work environment and tasks proposed to be undertaken from home, are to be reviewed as part of the Workers Compensation staff approval).

Yes No

Workers Compensation staff member nameSignature Date

PART C – EQUIPMENT REQUIREDTo be completed by the employee’s supervisor with the employee

List of required equipment to perform work from home (tick if applicable)To be provided by:

Employee

University**

* First aid kit* Smoke detector/ Fire alarm (functioning / in-date)* Fire controls (e.g. fire extinguisher, fire blanket) – Specify:

Head setComputerComputer screenMouseKeyboardPrinterDocument HolderComputer deskFully adjustable chairFootrestFiling / Storage equipmentTelephoneStationery

Other? Specify below:Emergency contact list

*Mandatory equipment requirements** The University is responsible for maintaining University equipment.

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Working from Home Agreement

PART D – COMMUNICATION ARRANGEMENTSTo be completed by the employee’s supervisor with the employee

Employee name:mobile phone number:home phone number:

(Co-workers MUST NOT provide an employee’s home number to any other person without the employee’s consent).

Employee work schedule by location Specify the days and/or hours the employee will be working in either their University office or from home

Employee contact / reporting requirements

When the employee is Working From Home, their University office phone number must be:

Diverted to their mobile phoneDiverted to their home phoneDiverted to / Answered by a co-worker:Other (specify): ____________________

When Working From Home, is the employee required to call or report in regularly to verify they are ok? Yes No If “YES”, complete details below:Specify any relevant communication procedures required between the employee (when Working From Home) and co-workers

If the employee or an employee’s co-worker has any issues or concerns with the employee’s Working From Home arrangement – please refer to:

(Name of Manager / Supervisor)

Contact Number

NOTIFICATION REQUIREMENTSPART E – DETERMINE WHO / WHAT NEEDS TO BE NOTIFIEDTo be completed by the employee’s Manager/Supervisor following approval for the employee to work from home.In addition to the actions/control measures identified in any attached assessments, the following notification actions must be undertaken BEFORE the employee can commence work from home:Actions Actioner Date

completeNotify IT regarding access to the campus network Manager /

Supervisor / /Notify the employee’s University work team of the Working From Home “Communication arrangements” (Refer Part D above)

Manager / Supervisor / /

Employee to have an “Emergency Contact List” available in their home office of numbers to call / persons to notify in an emergency situation.

Manager / Supervisor / /

Notify University Human Resources: Manager / Supervisor / /

A copy of this Working From Home assessment is to be put on the employee’s personal file once all actions are implemented.Other? (specify below – attach extra pages if required)

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