3.12 Out of territory remote work request form 工作表单原文件

Out-of-TerritoryRemoteWorkRequestForm

GAM3.12–RemoteWork

LastupdatedMarch2025|Page

PAGE

3

of

NUMPAGES

3

OUT-OF-TERRITORYREMOTEWORKREQUESTFORM

Purpose:ThisformisfordepartmentstorequestaremoteworkarrangementoutsideofYukonforanemployee.Sucharrangementsareapprovedonlyinexceptionalcircumstances,andrequestswillbeevaluatedbasedontheinformationprovidedinthisform.Pleasenotethatrequestsforremoteworkoutsideofthecountrywillnotbeapproved.See

Out-of-TerritoryRemoteWorkGuidelines

formoreinformation.

EMPLOYEEINFORMATION

Employeename:EnterEmployeeName

Employeeemail:EnterEmployeeemail

EmployeeID:EnterEmployeeID.

Remoteworkstartdate:Selectdate

Remoteworkenddate:Selectdate

Requestedout-of-territoryremoteworklocation

Pleasenote:locationmustbeinCanada.RemoteworkarrangementsoutsideofCanadawillnotbeapproved.

Streetaddress:Entertext

City:Entertext

Province/Territory:Entertext

Phonenumber:Entertext

POSITIONINFORMATION

Department:SelectDepartment

PositionTitle:Enterpositiontitle

PositionType:Enterpositiontype(e.g.permanent,term)

HoursofWork:

EnterHours(bi-weekly)

☐Full-time

☐Part-time

SUBMITTEDBY

HRContact:EnterHRContactName.

Date:Selectdate

DMApproval:[signature]

Date:Selectdate

PublicServiceCommissionerApproval:

[signature]

Date:Selectdate

SubmitcompletedrequestformstotheExecutiveAssistantforthePublicServiceCommissionerat:

PSC-Commissioner@yukon.ca

.

Iftherequestisapproved,thedepartmentwillreceiveafinalcopyofthisform.ApprovedrequestsmustbeenteredintotheMyHRsystem.ThedepartmentisthenresponsibleforcontactingPSCFinancetoarrangeforworker’scompensationcoverage.

RATIONALE

Checkallconsiderationsthatapply:

Operationalneeds:

☐ Thearrangementwillenabletheemployeeandworkunittomeetoperationalneeds

☐ Thearrangementcanavoidormitigateanyadverseimpactsoncolleaguesortheworkunit.

Positionsuitability:

☐ Thejobdutiescanbeeffectivelyperformedatanoff-site,out-of-territorylocation.

☐ Thenatureoftheworkallowsforthesecuretransfer,storageanduseofgovernmentmaterials.

Employeesuitability:

☐ Theemployeehasdemonstratedtheirabilitytomeetperformanceexpectations.

☐ Theemployeecanworkwellindependentlyandwithreducedface-to-facesupervision.

☐ Theemployeehastheabilitytoattendtheofficialworkplaceinpersonifrequired.

Remoteworkplacesuitability:

☐Theremoteworkplacemeetshealthandsafetyrequirements.(Pleasenote:theemployeeandsupervisorareresponsibleformeetingtheremoteworkhealthandsafetyrequirementsoutlinedinsection3oftheremoteworkpolicy.)

☐ Theremoteworkplacemeetsrequirementsfortheprotectionofconfidentialinformation.

☐ Theremoteworkplaceisrelativelyfreeofdistractions.

☐ ThedepartmentisconfidentthatYukongovernmentequipment,files,orothermaterialswillbereturnedattheendoftheremoteworkingassignment

Exceptionaland/ortime-limitedcircumstances

☐ Thereareexceptionalpersonalcircumstances,suchascompassionatereasons.

☐ Thenatureofthepositionisuniqueand/orhardtofill.

☐ Theremoteworkarrangementwouldpermitthedepartmenttomeetobjectives/prioritiesthatotherwisecouldnotbemet.

☐ Therequestisshort-termandtemporary,notapermanentarrangement.

**Pleasenote:Requestsforremoteworkoutsideofthecountrywillnotbeapproved.

Detailedrationale:

Pleaseexplainthecircumstancesofthisrequest,e.g.whatmakesthisanexceptionalcircumstance,andprovideanyadditionalinformationonanyoftheselectionsabove.

Clickheretoentertext.

Historyofrequest

Iftheemployeehaspreviouslybeenapprovedforanout-of-territoryremoteworkarrangement,pleasenotethestartandenddatesofpreviousarrangementsbelow.

Clickheretoentertext.

Approachtoworkhoursandleave

Out-of-territoryremoteworkarrangementsarenotintendedtobeareplacementfortheuseofleave,includingvacationorspecialleave.Pleaseindicateanychangestotheemployee’shoursofworkduringtheout-of-territoryarrangement,aswellasanyplanneduseofleave(forexample,specialleavetoattendappointmentswithanillrelative).

Clickheretoentertext.

Enddateforarrangement

Out-of-territoryremoteworkarrangementsaremeanttobetemporaryandshouldhaveaclearplantoend,eitherwiththeemployeereturningtotheterritoryortheemploymentrelationshipotherwiseending(retirement,etc.)Pleaseexplainplansfortheendofthisarrangement,including(ifrelevant)anyanticipatedrequestsforextension/renewal.TheremoteworkarrangementmustalsobeupdatedinMyHRwhenitends,toensureaccuratetrackingandreporting.

Clickheretoentertext.

Departmentjustification

(TobecompletedbydepartmentalHRand/ordeputyminister)

The

Guidanceforout-of-territoryremoteworkarrangements

notesthatitistheroleofseniordecision-makerstobalanceconflictingprinciplesandmakedecisionsinthebestinterestofthepublicservice.Pleaseexplainhowthisrequestbalancestheprinciplessetoutinsection3oftheguidance.

Clickheretoentertext.

CollectionNotice:

Personalinfo