1910F3 - Telework Request Form

Last Updated: 11/3/2020 8:47 PM

Belgrade School District - Employee Request Form - Temporary Tele-Work 1910F3

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Employees may be eligible for a temporary telework (telecommuting) accommodation. Employees can complete this form and submit it or any questions to the H.R. Department at the district administration building.

Section 1

  • Employee Name
  • Mailing Address
  • E-Mail
  • Home Phone Number
  • Alternate Phone Number
  • Anticipated Begin Date of Leave
  • Expected Return to work Date

Section 2


The Belgrade School District recognizes teleworking as a voluntary work plan, agreed upon between the School District, and the employee, in which the employee works at an alternative worksite on a regular basis on a specified schedule. Teleworking is an accommodation, not a District-wide benefit; and it in no way changes the terms and conditions of employment. Not all School District jobs are suitable for teleworking.

I am requesting the accommodation to telework for the following reason(s):


Please attach applicable documentation if appropriate.

Section 3


The employment relationship for an employee teleworking stays the same as for employees not working from an alternative worksite. Compensation does not change, and employees are expected to follow all existing job requirements, School District policies, guidelines and expectations that are in effect in the District. In addition, the employee shall honor the following guidelines:

  • a. Be available by phone and e-mail during normal work hours. Absences (including unavailability during work hours) must be pre-approved.
  • b. Promptly notify the supervisor when unable to perform work assignments due to illness, equipment failure, or other unforeseen circumstances.
  • c. Alter their schedule to attend mandatory meetings or other situations needing a physical presence and/or as needed by the supervisor or executive director.
  • d. Assure the alternative worksite is adequate and safe and has sufficient phone service; a secure internet connection with enough speed to perform work; and that confidential information will be safeguarded. The employee is responsible for the cost of these adequacy measures.
  • e. Use, exclusively, the computer and software provided and configured with security software by the School District.
  • f. Have adequate dependent care arrangements in place to ensure the employee's ability to telecommute. Report, at once, to their supervisor any injury that occurs at the alternative site during work hours.
  • h. Refrain from having in-person meetings or instruction at the alternative worksite unless preapproved by their supervisor

Supervisors will regularly check employee compliance with the teleworking agreement, relevant policies and guidelines, performance standards, expectations for work products, productivity and time accountability.

Teleworking plans are subject to change at the discretion of the School District.


Section 4


I certify that the above information is accurate and complete. I understand that if I fail to report for work on or before the scheduled return date indicated above or fail to honor the intermittent EFMLA schedule I may be subject to discipline in accordance with School District Policy.

  • Employee Signature
  • Date

Section 5


  • Request Received By
  • Date
  • Telework Approved By
  • Date
  • Period of Telework

The School District will retain all records related to this leave request for at least 4 years for auditing purposes.

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