20R0010-AttachA-DS1963CheckList.pdf

HOME SAFETY CHECKLIST FOR TELEWORKERS

DS-1963

05-2017

The following checklist is designed to assess the overall safety of your alternate duty station. Please read and complete the self-certification safety checklist. Upon completion, you and your supervisor should sign and date the checklist in the spaces provided.

No

Organization

Yes

Name (Last, First, MI)

U.S. Department of State

Alternate duty station phone number

The alternate duty station is Supervisor's Name

Briefly describe the designated work area in the alternate duty station.

Address City/State

A. Workplace Environment

1. The temperature, noise, ventilation and lighting levels are adequate for maintaining your normal level of job performance.

NoYes2. Stairs with four or more steps are equipped with handrails.

NoYes3. Circuit breakers and/or fuses in the electrical panel are labeled as to intended services.

NoYes4. Circuit breakers clearly indicate if they are in the open or closed position.

NoYes5. Electrical equipment is free of recognized hazards that would cause physical harm (frayed wires, bare conductors, loose wires, flexible wires running through walls, exposed wires to the ceiling).

NoYes6. The buildings electrical system permits the grounding of electrical equipment.

NoYes7. Aisles, doorways, and corners are free of obstructions to permit visibility and movement.

NoYes8. File cabinets and storage closets are arranged so drawers and doors do not open into walkways.

NoYes9.

NoYes10. Phone lines, electrical cords,and extension wires are secured, taped under a desk, alongside a baseboard, or under carpet.

NoYes11. Office space is neat, clean, and free of excessive amounts of combustibles.

NoYes12. Floor surfaces are clean, dry, level and free of worn or frayed seams.

NoYes13. Carpets are well secured to the floor and free of frayed or worn seams.

NoYes14. There is enough light for reading.

Elements of the desk chair secure and sturdy.

B. Computer Workstation

Approved Disapproved

Please return a copy to your bureau telework coordinator

DS-1963 Page 2 of 2

NoYes1. If your chair is adjustable you know how to adjust it.

NoYes2. Your back is adequately supported by a backrest.

NoYes3. Your feet are either on the floor or fully supported by a footrest.

NoYes4. You are satisfied with the placement of your monitor and keyboard.

NoYes5. The text on your screen is free from noticeable glare and easy to read.

NoYes6. If you require a document holder, you have one.

NoYes7. You have enough leg room at your desk.

NoYes8. The top of the screen is level.

NoYes9. There is space to rest your arms while keying and your forearms are parallel with the floor when keying.

NoYes10. Your wrists are fairly straight when keying.

NoYes11. Your home workstation is ergonomically correct.

PRIVACY ACT STATEMENT

Authority This information is sought under authority of the Telework Enhancement Act of 2010 (5 U.S.C. 6501 et. seq.) and 5 CFR 531.605.

Purpose The information solicited on this form will be used to ensure eligibility in the Telework program, to validate the employee's performance of a home safety check and to facilitate timely processing of the request.

Routine Uses The information on this form is for administrative purposes and will not be shared with anyone outside the State Department. More information on the Routine Uses for the system can be found in System of Records Notice, State-31, Human Resources Records.

Disclosure The information requested on this form is voluntary but failure to provide the requested information may delay or result in disapproval of your

Telework request.

Signing Instructions

Employee Signature Date (mm-dd-yyyy)

(User Name)

Immediate Supervisor Signature Date (mm-dd-yyyy)

(User Name)