Safety Checklist For Home-Based Teleworkers
The following checklist is designed to assess the overall safety of your alternative worksite. 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.
Name: _____________________________________________________________
Organization: ________________________________________________________
Address: ____________________________________________________________
City/State: __________________________________________________________
Business Telephone: __________________________________________________
Telecommuting Coordinator: ____________________________________________
Alternative Worksite Location: ___________________________________________
(Describe the designated work area at the alternative worksite & attach a photograph or plan)
A. Workplace Environment
1. Are temperature, noise, ventilation and lighting levels adequate for maintaining your normal level of job performance?
Yes [ ] No [ ]
2. Are all stairs with four or more steps equipped with handrails? Yes [ ] No [ ]
3. Are all circuit breakers and/or fuses in the electrical panel labeled as to circuit served?
Yes [ ] No [ ]
4. Do circuit breakers clearly indicate if they are in the open or closed position? Yes [ ] No [ ]
5. Is all electrical equipment free of recognized hazards that would cause physical harm (frayed wires, loose wires, flexible wires running through walls, exposed wires to the ceiling)?
Yes [ ] No [ ]
6. Does the building's electrical system permit the grounding of electrical equipment? Yes [ ] No [ ]
7. Are aisles, doorways, and corners free of obstructions to permit safe movement? Yes [ ] No [ ]
8. Are file cabinets and storage closets arranged so drawers and doors do not open into walkways?
Yes [ ] No [ ]
9. Do chairs have any loose casters (wheels) and are sturdy, stable and designed to not tip backwards?
Yes [ ] No [ ]
10. Are the phone lines, electrical cords, and extension wires secured under a desk or alongside a baseboard, not likely to become entangled in your feet? Yes [ ] No [ ]
11. Is the office space neat, clean, and free of excessive amounts of combustibles? Yes [ ] No [ ]
12. Are floor surfaces clean, dry, level, and free of worn or frayed seams? Yes [ ] No [ ]
13. Are carpets well secured to the floor and free of frayed or worn seams? Yes [ ] No [ ]
14. Is there enough light for reading? Yes [ ] No [ ]
B. Computer Workstation (if applicable)
15. Is your chair adjustable? Yes [ ] No [ ]
16. Do you know how to adjust your chair? Yes [ ] No [ ]
17. Is your back adequately supported by a backrest? Yes [ ] No [ ]
18. Are your feet on the floor or fully supported by a footrest? Yes [ ] No [ ]
19. Are you satisfied with the placement of your monitor and keyboard? Yes [ ] No [ ]
20. Is it easy to read the text on your screen? Yes [ ] No [ ]
21. Do you need a document holder? Yes [ ] No [ ]
22. Do you have enough legroom at your desk? Yes [ ] No [ ]
23. Is the screen free from noticeable glare? Yes [ ] No [ ]
24. Is the top of the screen at eye level? Yes [ ] No [ ]
25. Is there space to rest the arms while not keying? Yes [ ] No [ ]
26. When keying, are your forearms close to parallel with the floor? Yes [ ] No [ ]
27. Are your wrists fairly straight when keying? Yes [ ] No [ ]
Employee's Signature and Date: ___________________________________________
Immediate Supervisor's Signature and Date: __________________________________
Approved [ ] Disapproved [ ]
Please return a copy of this form to your telecommuting program coordinator.
