Sample Self-certification Safety Checklist* For Home-based Teleworkers

Name:

Organization:

Address:

City/State:

Business Telephone:

Telecommuting Coordinator:

Alternative Worksite Location:
(Describe the designated work area in the alternative worksite.)

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 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)

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 leg room at your desk? Yes [     ] No [     ]

23. Is the screen free from noticeable glare? Yes [     ] No [     ]

24. Is the top of the screen 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.

* This checklist was developed by the General Services Administration.