Self Certification Safety Checklist - SAMPLE.pdf

SELF-CERTIFICATION SAFETY CHECKLIST FOR

HOME-BASED TELEWORKERS - SAMPLE

Name: ________________________________________

Organization/Office: _______________________________________

Location: _______________________________________

Phone: ________________________________________

The following checklist is designed to assess the overall safety of the alternate worksite. Each participant should read and complete the self-certification safety checklist. Upon completion, the checklist should be signed and dated by the participating employee and his/her manager.

The alternate worksite is located at: ________________________________________

Describe the designated work area: ________________________________________

A. WORKPLACE ENVIRONMENT

1. Are temperature, noise, ventilation, and lighting levels adequate to maintain your normal level of job performance? Yes ( ) No ( )

2. Are all stairs with four or more steps equipped with handrails? Yes ( ) No ( )

3. Does the electrical system conform to appropriate local building codes? Yes ( ) No ( )

4. Are aisles, doorways, and corners free of obstructions to permit visibility and movement? Yes ( ) No ( )

5. Are file cabinets and storage closets arranged so drawers and doors do not open into walkways? Yes ( ) No ( )

6. Are chairs free of loose casters (wheels) and are legs of the chairs sturdy? Yes ( ) No ( )

7. Are the phone lines, electrical cords, and extension wires secured under a desk or alongside a baseboard? Yes ( ) No ( )

8. Is the office space neat, clear, and free of excessive amounts of combustibles? Yes ( ) No ( )

9. Are floor surfaces (including carpets) clean, dry, level, and free of worn or frayed seams? Yes ( ) No ( )

10. Is there enough light for reading? Yes ( ) No ( )

B. COMPUTER WORKSTATION (IF APPLICABLE)

11. Is your chair adjustable? Yes ( ) No ( )

12. Is your back adequately supported by a backrest? Yes ( ) No ( )

13. Is your computer monitor eye level? Yes ( ) No ( )

14. When keying, are your forearms close to parallel with the floor? Yes ( ) No ( )

15. Are your wrists fairly straight when keying? Yes ( ) No ( )

Employees requesting approval to Telework must affirm Questions 1-15 or agree that the alternate environment is conducive to performing at an acceptable level in order to have an Approved Telework Agreement.

Employee Signature _______________________________ Date _______________

Manager Signature _______________________________ Date _______________