Name of Telecommuter:                                                                                                                          *

Address/Location of Telecommuting:                                                                                                     *

Name of Supervisor:                                                            Department:                                              *
Home based telecommuting is a work arrangement made by mutual agreement and can be discontinued
by the Dean/Director or employee at any time, normally with a 30-calendar day notice.
Prior to signing below, discuss the Telecommuting Home Safety Guidelines.
Purpose for Telecommuting:
 

Primary performance expectations (attach a copy of current position description to include organization chart)
 

Work Schedule: (attach completed form HR #101)
Dates of telecommuting assignment:

   Beginning Date:                                                       Ending Date:                                                      *

*Day (s) of the week employee is working on campus:                                                                       *
The University will pay for business related expenses including telephone calls and Internet access,
maintenance and repairs of state owned equipment.  Claims must be submitted on a Travel Expense
Claim  in accordance with University guidelines.  Replacement of state owned equipment that is stolen
or destroyed will be the responsibility of the telecommuter’s homeowners/renters insurance, up to the
limits of such policy(s).   Replacement cost above personal policy limits will be the responsibility of SFSU.