Remote Work and Telecommuting Manager’s Approval Form

Ensure that managers who review an employee’s application for permission to engage in remote work evaluate consistent and appropriate criteria in making their decision. You can accomplish that objective by requiring reviewing managers to complete a form documenting their review and decision. Here’s a template form you can adapt. Require managers to submit the completed form to HR and attach a blank copy of it as an Appendix to your Remote Work Policy.

Employee Information

Employee: _______________________________________

Position: ________________________________________

Department: _____________________________________

Supervisor: ______________________________________

Date of Request: ________________________________

Requested Effective Date: _________________________

Type of Arrangement:

☐ Full-Time Remote

☐ Hybrid

☐ Temporary Remote

☐ Accommodation-Related Remote Work

☐ Other: ______________________________

Part A – Operational Review

Item	Yes	No	N/A
Position is suitable for remote work.	☐	☐	☐
Employee meets performance standards for remote work.	☐	☐	☐
Employee has not been subject to recent disciplinary action.	☐	☐	☐
Essential job duties can be performed remotely.	☐	☐	☐
Required customer or operational coverage can be maintained.	☐	☐	☐
Team communication needs can be met.	☐	☐	☐
Productivity expectations have been discussed.	☐	☐	☐
Performance measures have been established.	☐	☐	☐

Comments:

Part B – Telework Documentation

Confirm that the following documents have been completed.

Document	Completed
Remote Work Request	☐
Remote Work Agreement	☐
Remote Work Safety Self-Assessment Checklist	☐
Remote Work Security Standard Acknowledgement	☐
Confidentiality Agreement (if applicable)	☐
Accommodation Documentation (if applicable)	☐

Part C – Health and Safety Review

Requirement	Yes	No	N/A
Home workspace reviewed.	☐	☐	☐
Any identified hazards addressed.	☐	☐	☐
Ergonomic concerns resolved or action plan established.	☐	☐	☐
Employee understands injury reporting procedures.	☐	☐	☐
Employee understands emergency procedures.	☐	☐	☐

Comments:

Part D – Information Security Review

Requirement	Yes	No	N/A
Company-approved device issued or approved.	☐	☐	☐
VPN access configured (if required).	☐	☐	☐
Multi-factor authentication enabled.	☐	☐	☐
Required software installed.	☐	☐	☐
Employee completed required cybersecurity training.	☐	☐	☐
Access rights reviewed.	☐	☐	☐

Comments:

Part E – Legal & HR Review

Confirm the following have been considered where applicable.

Item	Yes	No	N/A
Employment standards implications reviewed.	☐	☐	☐
Occupational health and safety obligations reviewed.	☐	☐	☐
Workers’ compensation implications reviewed.	☐	☐	☐
Privacy requirements reviewed.	☐	☐	☐
Payroll implications reviewed.	☐	☐	☐
Human rights accommodation issues addressed (if applicable).	☐	☐	☐
Proposed work location is within the approved province.	☐	☐	☐
Cross-border or out-of-province work has been separately approved (if applicable).	☐	☐	☐

Comments:

Part F – Equipment Issued

Equipment	Issued
Laptop	☐
Docking Station	☐
Monitor	☐
Keyboard	☐
Mouse	☐
Headset	☐
Mobile Phone	☐
Printer (if approved)	☐
Ergonomic Chair	☐
Other: ________________________	☐

Asset Numbers:

Part G – Remote Work Conditions

The following conditions apply to this approval:

☐ Approved work location only

☐ Approved work schedule only

☐ Mandatory in-office attendance on specified days

☐ Quarterly review

☐ Annual workspace reassessment

☐ Additional cybersecurity training

☐ Other:

Part H – Decision

☐ Approved

Effective Date:

☐ Conditionally Approved

Conditions:

☐ Not Approved

Reason(s):

Follow-Up Review

Next Review Date:

Responsible Manager:

Manager Certification

I have reviewed this request and, to the best of my knowledge, the required operational, health and safety, information security, privacy and human resources considerations have been addressed before approving this remote work arrangement.

Manager

Date

HR Review (If Required)

☐ Approved

☐ Additional Review Required

Comments:

HR Representative

Date

Information Technology Review (If Required)

☐ Completed

☐ Additional Action Required

Comments:

IT Representative

Date