NAME: _________________________________________________
ORGANIZATION: ________________________________________
ADDRESS: ______________________________________________
CITY/STATE: ____________________________________________
BUSINESS TELEPHONE:__________________________________
TELECOMMUTING (FLEXIPLACE)
COORDINATOR: ________________________________________
Dear Telecommuter:
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.
The alternate duty station is ________________________________________.
Describe the designated work area in the alternate duty station:
________________________________________________________________.
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 4 or more steps equipped with handrails? | Yes ___ No ___ |
3. Are all circuit breakers and/or fuses in the electrical panel labeled as to intended service? | 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, bare conductors, loose wires, flexible wires running through walls, exposed wires to the ceiling)? | Yes ___ No ___ |
6. Will the building's electrical system permit the grounding of electrical equipment? | Yes ___ No ___ |
7. Are aisles, doorways, and corners free of obstructions to permit visibility and 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 the rungs and legs of the chairs sturdy? | Yes ___ No ___ |
10. Are the phone lines, electrical cords, and extension wires secured under a desk or alongside a baseboard? | 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) |
1. Is your chair adjustable? | Yes ___ No ___ |
2. Do you know how to adjust your chair? | Yes ___ No ___ |
3. Is your back adequately supported by a backrest? | Yes ___ No ___ |
4. Are your feet on the floor or fully supported by a footrest? | Yes ___ No ___ |
5. Are you satisfied with the placement of your VDT and keyboard? | Yes ___ No ___ |
6. Is it easy to read the text on your screen? | Yes ___ No ___ |
7. Do you need a document holder? | Yes ___ No ___ |
8. Do you have enough leg room at your desk? | Yes ___ No ___ |
9. Is the VDT screen free from noticeable glare? | Yes ___ No ___ |
10. Is the top of the VDT screen eye level? | Yes ___ No ___ |
11. Is there space to rest the arms while not keying? | Yes ___ No ___ |
12. When keying, are your forearms close to parallel with the floor? | Yes ___ No ___ |
13. Are your wrists fairly straight when keying? | Yes ___ No ___ |
________________________________________________________________
Employee Signature Date
________________________________________________________________
Immediate Supervisor's Signature Date
Approved [ ] Disapproved [ ]
PLEASE RETURN A COPY OF THIS FORM TO YOUR
FLEXIPLACE COORDINATOR
INFORMATIONFor more information, contact Dr. Wendell Joice on (202) 273-4664, or email at wendell.joice@gsa.gov