Your State department is collecting information on STD 200, Telework Agreement as authorized by Government Code sections 14200—14203 and the Telework Policy, State Administrative Manual Management Memo 21-08. The information provided is subject to, but not limited to Civil Code Section 1798.24 and the Information Practices Act. All fields are required to be completed in STD. 200. Failure to provide all required information will result in delay or denial of your telework agreement. The information is collected for the purpose of administering the telework program and for the purpose of validating appropriateness of alternate work location and aggregate report on telework effectiveness. Additionally, the information may be used for assessing the benefits of telework to the employee and State. The aggregate de-identified information may be shared publicly. The State of California will not disclose personal information unless required to do so by law. You have the right to access the records containing the personal information that you provided. For questions about this notice and access to your records, contact your department Telework Coordinator.

Section A: Request Type

01. New Telework Agreement – Select this if a new Telework Agreement (TWA) is requested. Upon selection, you will be prompted to fill out sections B, C, and D. Acknowledge section E. Read section G; Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will fill out section F and sign on their respective signature line.

02. Modify Telework Agreement – Select this to request changes to an existing and approved Telework Agreement in active status. Upon selection, you will be prompted to fill out sections B, C, and D. Acknowledge section E. Read Section H. Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will fill out section F and sign on their respective signature line.

03. Terminate Telework Agreement – Select this to terminate an existing and approved Telework Agreement. Upon selection, you will be prompted to fill out section B. Read section I. Enter the termination effective date; Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line. Follow your department TWA termination processes for both the telework agreement and telework equipment return. NOTE: Supervisors and managers should check with their Labor Relations consultant prior to terminating a TWA

04. Annual Review – Select this if the Annual Review of the Telework Agreement is being performed. Upon selection, you will be prompted to fill out section B. Check the appropriate box on section J and follow any further instructions provided. Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line.

Section B: Employee Information

01: Name – Enter Employee Name: First, Middle Initial, and Last. Enter email.

02, 03: Employee ID and Position Number – Enter Employee ID and Position Number.

Find your Employee ID and Position Number on Cal Employee Connect. Once logged in, click on your name in the upper right-hand corner and select User Profile. You will find your Unique Employee ID (UEID) and Position Number under Employee Information. If you have not registered, please click the Register icon. You will need the following information from a single earnings statement (paper warrant/paystub or direct deposit advice).

• Department or Campus Name
• Agency Code
• Social Security Number (SSN)
• Date of Birth
• Warrant number or direct deposit number
• Total Deductions

If you do not have any earnings statements, please contact your HR office to obtain required warrant number and deductions information.

04: Collective Bargaining Identifier (CBID) – Enter CBID.

The CBID information can be found in the CalHR Pay Scale. Select option 15 for an alphabetical listing of Classifications. Find your classification. The CBID will be located in the last column on the right. For the CBID information, include appropriate letter (M, S, C, R) and the unit number.

05: Enter your supervisor’s first and last name.

06: Enter your supervisor’s email, as a copy of this form will be sent to them upon submit. You will be cc’d in that email.

Fields collection in section C.

¹These fields may be used for calculating metrics associated with telework. Address information is not published. It may be used for calculating potential savings from miles and time not traveled. The office address is the physical location the employee would report to if they were not teleworking.

² Privacy related information

Address information may be used for:

• Validating appropriateness of alternate work location
• Aggregate reporting on telework effectiveness – not identifying individuals
• Computing mileage and time to derive benefits of telework to the employee and state

Section C: General Provisions

1: Read the provision carefully. Provide initials in the checkbox to acknowledge agreement.

2A: Addresses – Enter the address of designated alternate work location. Select your Office Location. The office adress will be auto-filled based on location selection. If you select Other, you will manually enter your Office address in the new fields provided. Provide initials in the checkbox to acknowledge agreement.

2B: Calculate the two fields by entering addresses in Google maps. See instructions here.

3: Enter the phone number for which the employee will be reachable during telework. Provide initials in the checkbox to acknowledge agreement.

4: Work Schedule – Enter the Employee’s planned work schedule for an average week. Select the radio button for Office, Telework, or Day Off. If Office or Telework are selected, enter the start time and end time for each work day. Only use 15 minute increments.

Select Employee’s work schedule. The choices are:

• Standard – standard 40-hour work week with 8-hour work days and is the defaultvalue.
• FT_AWWS 9/8/80 – 80-hours over two weeks. 9-hour days with one day off every 2weeks.
• FT_AWWS 4/10/40 – 40-hour work week, 10-hour days and 1 day off.
• Other (if selected, you will type your explanation in a new field).

Provide the average number of days per week you will be working. Provide the average number of days per week teleworking. For example, with a 9/8/80 schedule, perhaps an employee teleworks 3 days during the full week and 2 days during the week with the day off. In this case the average days teleworked will be 2.5 days per week.

Remote Centered Employee – Select this radio button if the employee works 50 percent or more of their time monthly from an alternate work location.

Office Centered Employee – Select this radio button if the employee works more than 50 percent of their time monthly from the office headquarter location.

Enter the Telework Agreement effective start date.

Make any notations about the work schedule not captured in the above fields. If there are no additional notes required, enter “N/A.” If the employee is on the 9/8/80 alternate work week schedule, enter notes to indicate what day of the week the employee will have off every two weeks. If more space is needed, enter information on to a Word document and attach to the form.

Provide initials in the checkbox to acknowledge agreement.

5: Read the provision carefully. Employee provides initials in the checkbox to acknowledge agreement. Attach a copy of your job duty statement to the form.

6-14: Read each provision carefully. Employee provides initials in the checkbox to acknowledge agreement.

Section D: Technology and Equipment

List the equipment that will be used to support teleworking. Enter whether it is personally owned or department provided. If department provided, enter the asset tag number if available.

Section E: Scope of Agreement

Read the scope of agreement carefully. Provide initials in the checkbox to acknowledge agreement.

Section F: To be Completed by Supervisor

01: Check “Approved” if you will be approving the telework agreement request.

02: Meet with your Labor Relations (LR) Consultant prior to denying a telework agreement request.Follow your department procedures for denials.Check “Denied” if you will be denying the telework agreement request and provide the reason(s) in the space provided for your denial as per your consultation with Labor Relations.

03: Check “Returned for Corrections” if there you discovered errors in the submitted request. Provide the corrections needed in the space provided. Return the form to the employee and request that the employee submit a corrected request using the “New Telework Agreement” option.

Section G: New Telework Agreement Acknowledgement

Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line. Original should be maintained by the department’s Telework Coordinator, with a copy provided to the Employee and Supervisor. In the event the form is maintained digitally, the electronic signature is maintained in a centralized database accessible by department’s Telework Coordinator. It is recommended that the form be signed electronically for greater safety of privacy information. If the Telework Agreement is printed, all parties should implement Information Privacy Policy guidelines to ensure confidentiality and safety of privacy information.

Section H: Modify Telework Agreement

Provide initials in the checkbox to acknowledge there will be modifications to the current telework agreement. Follow your department telework agreement procedures for modifications.

Enter the modification date in MM/DD/YYYY format.

Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line.. Original should be maintained by the department’s Telework Coordinator, with a copy provided to the Employee and Supervisor. In the event the form is maintained digitally, the electronic signature is maintained in a centralized database accessible by department’s Telework Coordinator. It is recommended that the form be signed electronically for greater safety of privacy information. If the Telework Agreement is printed, all parties should implement Information Privacy Policy guidelines to ensure confidentiality and safety of privacy information.

Section I: Terminate Telework Agreement

Provide initials in the checkbox to acknowledge you will be terminating the telework agreement. Follow your department telework agreement process for terminations.

Enter the termination date in MM/DD/YYYY format.

Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line. Original should be maintained by the department’s Telework Coordinator, with a copy provided to the Employee and Supervisor. In the event the form is maintained digitally, the electronic signature is maintained in a centralized database accessible by department’s Telework Coordinator. It is recommended that the form be signed electronically for greater safety of privacy information. If the Telework Agreement is printed, all parties should implement Information Privacy Policy guidelines to ensure confidentiality and safety of privacy information.

Section J: Annual Review

The Telework Agreement is to be reviewed annually. Use this section after the active Agreement has been reviewed by both the employee and the supervisor.

If it is determined that the telework agreement will be modified, check the box indicating that it will be modified. Follow your department telework agreement modification process.

If it is determined that there are no changes to be made to the previous year’s Agreement, check the appropriate box stating that there are no changes.

Enter the year the review is taking place.

Employee will digitally sign. Upon completion of this webform, the form will be emailed to your supervisor and they will sign on their respective signature line.

Follow document retention and privacy guidelines.