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I can't help you with the precise wording of such a policy, but I can help you with the general best practices on which you can base your policy. I've created a short video on this subject here:
The way we've implemented this within our organization is that we've converted some of those best practices into "rules", i.e., things you absolutely HAVE to do if you want to continue working from home.
Hope this helps!
From India, Mumbai