Informed Consent Form s2

City of Tacoma Telecommuting Application and Informed Consent

Name______Office Phone______

Office Phone while Telecommuting ______

Why Do You Want to Telecommute? ______

Why do you believe that you will be an effective telecommuter? ______

Proposed Schedule

The study requires telecommuting 12 days during the month you will be telecommuting. If approved for participation, which days of the week would you plan to telecommute?

Monday Tuesday Wednesday Thursday Friday Variable

If variable, specify the month and dates you plan to telecommute: ______

Typical telecommute day schedule: Start______Lunch______End______Where do you plan to work on telecommuting days? Home Office Other

If other, please specify the alternate work location______

Do you have a room or an area at home or at your alternate work location with privacy that you can dedicate to your use during telecommuting? Yes No

Equipment

Check which of the following items that you currently have in your home office or alternative work site:

Computer (Windows XP OS required) Surge Protector Calculator

Cell Phone Fax Machine Printer Answering Machine/Voice Mail Email

Work Related Software (Microsoft Office or equivalent)

Experience

Have you ever telecommuted before? Yes No

If yes, please describe your experience: ______

Employee’s Signature______Date ______

Approved Denied

Reason(s) for Denial ______Informed Consent Form

The City of Tacoma will be conducting a two-month pilot study to investigate the impacts of telecommuting on the City’s greenhouse gas emissions. Study participants will be volunteers who obtain their supervisor and division or department manager’s approval and are not planning to be on vacation during the study months of August and September 2007.

Submission of this application and Informed Consent Form is not a guarantee that the employee will be able to participate in the study.

The City of Tacoma supports the practice of protection for human participants in research and related activities. The following information is provided so that you can decide whether you wish to participate in the present study. You should be aware that even if you agree to participate, you are free to withdraw at any time, and that if you do withdraw from the study, you will not be subjected to reprimand or any other form of reproach.

Procedures to be followed in the study, identification of any procedures that are experimental, and approximate time it will take to participate:

The study will last for two months and may be continued with group and management approval. Participants will attend two half-day training sessions where they will learn about the study and learn the expectations of the City during the study period.

Prior to beginning the study, participants will fill out a survey which asks information regarding typical driving habits, the driving habits of other drivers in the household, the types of cars in the household and any modifications that have been done to the vehicles that might affect their emissions. We will also obtain the odometer mileage for each vehicle in your household prior to the beginning of the two-month study period. Other questions will assess employee attitudes and opinions about telecommuting and environmental issues in general.

The study will require that you report the total mileage each of your vehicles travels each week of the two-month period. Reporting will be either via e-mail or Web site. The study manager may also contact you via phone or e-mail during the study to see if you have any questions and how things are progressing. After the two-month pilot period, participants will fill out another survey asking for feedback on the pilot process itself and suggestions for improving the program. Additionally, the survey will ask questions about employee attitudes and opinions.

Participation time is expected to take no more than 30 minutes (to complete the initial survey) and five minutes per week to record each household vehicle’s mileage for the week.

Employees are responsible for complying with the requirements of the City’s Telecommuting guidelines in Personnel Management Policy 325. Employees will be responsible for the security of any City information that they take home with them and for the security of the City’s computer network while at home. Employees must not leave the computer unattended while logged into the City system.

Description of any attendant discomforts or other forms of risk involved for those taking part in the study:

There may be potential risks from home office safety issues and normal risks from driving. Employees are encouraged to ensure that their home office space is a safe working environment. The City reserves the right to inspect the employee’s home office at the City’s discretion.

Description of benefits to be expected from the study or research:

1) The City will have information on the impacts to the City’s greenhouse gas emissions from a City-wide telecommuting program.

2) The City will have information on the impacts to employee morale and productivity from a telecommuting program.

3) The City will be able to identify other benefits and hurdles that might arise from a broader telecommuting program.

4) The City will have a minimum of 40 employees and 40 managers who have a better understanding of the benefits and drawbacks of telecommuting and the issues that arise between managers and employees who telecommute. Employee Acknowledgement and Agreement to Participate

I have read the above statement and have been fully advised of the procedures to be used in this project. I have been given sufficient opportunity to ask any questions I had concerning the procedures and possible risks involved. I understand the potential risks involved, and I assume them voluntarily. I likewise understand that I can withdraw from the study at any time without being subjected to reproach. I may also ask for a summary of the results of this study. If I have questions I may contact the investigator, Bill Smith, at 253-593-7719.

Signature Date Employee

Signature Date Employee Supervisor

Signature______Date ______Division/Department Manager