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

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INFORMATION

For more information, contact Dr. Wendell Joice on (202) 273-4664, or email at wendell.joice@gsa.gov