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*Sample Checklist was taken from other employers’ telecommuting material. 1
Attachment B
*SAMPLE CHECKLIST AND EMPLOYEE
CERTIFICATION FORM
EMPLOYEE NAME:
AGENCY:
SUPERVISOR NAME:
LOCATION:
PHONE:
The following checklist is designed to assess the overall safety of the alternate work location. 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 immediate supervisor.
The alternate work location is located (check one): o in home
o not in home
Describe the designated work area: _______________________________________________
___________________________________________________________________________
_
___________________________________________________________________________
_
To the best of one’s knowledge:
1. Is the space free of asbestos-containing materials? YES NO
2. If asbestos-containing material is present, is it undamaged and in good
condition? YES NO
3. Is the space free of indoor air quality problems? YES NO
4. Is there adequate ventilation for the desired occupancy? YES NO
5. Is the space free of noise hazards (noises in excess of 85 decibels)? YES NO
6. Is there a potable (drinkable) water supply? YES NO
7. Are lavatories available with hot and cold running water? YES NO
8. Are all stairs with four or more steps equipped with handrails? YES NO
9. Are all circuit breakers and/or fuses in the electrical panel labeled as to
intended service? YES NO
10. Do circuit breakers clearly indicate if they are in the open or closed position?
YES NO
11. 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 fixed to the ceiling)? YES NO
Employee Checklist Template
source: resources.dhrm.virginia.gov
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