Telework Eligibility Questionnaire Form
Complete this questionnaire to help determine your eligibility for telework based on your role, work environment, and readiness.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Department or Team
*
Please Select
Administration
Operations
IT
Finance
Marketing
Sales
Other
Is your job function suitable for remote work?
*
Yes, fully suitable
Partially suitable
Not suitable
Which of the following do you have access to at home? (Select all that apply)
*
Reliable high-speed internet
Company laptop or desktop
Secure workspace (private and quiet)
Phone or VoIP access
Other
How would you rate your ability to stay productive when working remotely?
*
Not productive
1
2
3
4
Highly productive
5
1 is Not productive, 5 is Highly productive
Have you previously worked from home or teleworked?
*
Yes, regularly
Yes, occasionally
No, never
Do you have any concerns about remote work (e.g., communication, collaboration, distractions)?
Does your manager support telework for your role?
*
Yes
No
Not sure
Please describe any specific needs or accommodations required for you to work effectively from home.
Submit
Should be Empty: