Working from Home Agreement

APPLICATION
Employee 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 documents
The following may be required for this Working from Home Agreement to be reviewed:
WHAT HOW
Complete the Home-based The employee completes and attaches the Home-Based Work
Assessment Checklist. Assessment Checklist
Determine tasks, and The employee and supervisor complete the Work Arrangements
supervision, training and section (included in this agreement document)
equipment required to safely If applicable, the employee attaches any extra risk assessment
work from home. documentation, refer Project and Task Risk Management Procedure
Outline schedules, contact The employee and manager/supervisor complete the Communication
and reporting arrangements. Arrangements section (included in this agreement document)
Determine who/what needs The manager/supervisor completes the Notification Requirements
to be notified section (included in this agreement document)

APPROVAL
Manager / Supervisor Approval To be completed by the employee’s Manager/Supervisor
Is the employee approved No - Discuss the reason(s) why with
to work from home? Yes
the employee
Working From Home
End date:
Arrangement - Start Date Maximum term 3 years
Routine WHS inspection of To be conducted by the employee every:
home office (Specify frequency; e.g. 6 months).
Name
Manager /
Supervisor
Signature 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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PART A – WORK ARRANGEMENTS: Proposed Tasks, Supervision and Training

To be completed by the employee’s Manager/Supervisor with the employee
Clearly 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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PART B – EMPLOYEE ASSESSMENT: Workers Compensation and Rehabilitation

To be completed by the employee (and Workers’ Compensation staff if applicable)

Medical Result Action to be taken / Comments

Does the employee have a pre-existing injury If “yes”, discuss and answer questions below
that may be aggravated by performing with University Workers’ Compensation staff
Yes No
University work tasks from home? prior to proceeding.
If “no”, skip to Part C. below.
Has the employee seen a health / medical Yes
No
professional about this issue? N/A
Does the employee have any
Yes
recommendations from a health / medical No
N/A
professional?
University Workers Compensation
Result Action to be taken / Comments
approval (if applicable)
Is the employee approved to work from home?

(The suitability of the home based work

environment and tasks proposed to be Yes No
undertaken from home, are to be reviewed as
part of the Workers Compensation staff
approval).
Workers Compensation staff
member name
Signature Date

PART C – EQUIPMENT REQUIRED

To be completed by the employee’s supervisor with the employee
To be provided by:
List of required equipment to perform work from home (tick if applicable)
Employee University**
* First aid kit
* Smoke detector/ Fire alarm (functioning / in-date)
* Fire controls (e.g. fire extinguisher, fire blanket) – Specify:
Head set
Computer
Computer screen
Mouse
Keyboard
Printer
Document Holder
Computer desk
Fully adjustable chair
Footrest
Filing / Storage equipment
Telephone
Stationery
Other? Specify below:
Emergency contact list

*Mandatory equipment requirements

** The University is responsible for maintaining University equipment.

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PART D – COMMUNICATION ARRANGEMENTS

To 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

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

Contact
any issues or concerns with the employee’s (Name of Manager / Number
Working From Home arrangement – please refer to: Supervisor)

NOTIFICATION REQUIREMENTS
PART E – DETERMINE WHO / WHAT NEEDS TO BE NOTIFIED
To 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 complete
Notify IT regarding access to the campus network Manager / Supervisor / /
Notify the employee’s University work team of the Working From Home
Manager / Supervisor
“Communication arrangements” (Refer Part D above) / /
Employee to have an “Emergency Contact List” available in their home
Manager / Supervisor
office of numbers to call / persons to notify in an emergency situation. / /
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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