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NAME:________________________________________ AGENCY: ______________________________________ ADDRESS: _______________________________________ CITY/STATE: _______________________________________ BUSINESS TELEPHONE: _____________________________ SUPERVISOR: _____________________________________
Dear Flexiplace Program Participant:
The following checklist is designed to assess the overall safety of the alternate duty station. Each participant should read and complete the self-certification safety checklist. Upon completion the checklist should be signed and dated by the participant employee and immediate supervisor. The alternate duty station is .
Describe the designated work area in the alternate duty station.
A. WORKPLACE ENVIRONMENT 1. Are all stairs with 4 or more steps equipped with handrails? Yes No 2. Are all circuit breakers and/or fuses in the electrical panel labeled as to intended service? Yes No 3. Do circuit breakers clearly indicate if they are in the open or closed position? Yes No 4. 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 5. Will the building's electrical system permit the grounding of electrical equipment? Yes No 6. Are aisles, doorways, and corners free of obstructions to permit visibility and movement? Yes No 7. Are file cabinets and storage closets arranged so drawers and doors do not open into walkways? Yes No 8. Are chairs safe? (No loose casters (wheels) or rungs and legs of chairs are sturdy) Yes No 9. Are the phone lines, electrical cords, and extension wires secured under a desk or alongside a baseboard? Yes No 10. Is the office space neat, clean, and free of excessive amounts of combustibles? Yes No 11. Are floor surfaces clean, dry, level, and free of worn or frayed seams? Yes No 12. Are carpets well secured to the floor and free of frayed or worn seams? Yes No 13. Is there enough light for reading? Yes No
B. COMPUTER WORKSTATION (IF APPLICABLE) 14. Is your chair adjustable? Yes No 15. Do you know how to adjust your chair? Yes No 16. Is your back adequately supported by a backrest? Yes No 17. Are your feet on the floor or fully supported by a footrest? Yes No 18. Are you satisfied with the placement of your VDT and keyboard? Yes No 19. Is it easy to read the text on your screen? Yes No 20. Do you need a document holder? Yes No 21. Do you have enough leg room at your desk? Yes No 22. Is the VDT screen free from noticeable glare? Yes No 23. Is the top of the VDT screen eye level? Yes No 24. Is there space to rest the arms while not keying? Yes No 25. When keying, are your forearms close to parallel with the floor? Yes No 26. Are your wrists fairly straight when keying? Yes No
Employee Signature: ________________________________
Date:________________
Immediate Supervisor's Signature______________________
Date:________________
NOTE: Supervisor should retain a copy of this Employee Self-Certification Safety Checklist along with the written Flexiplace agreement. This safety checklist is intended to be a guide for the employee and the supervisor. If either the employee or the supervisor has concerns as to whether the prospective alternative work site is adequate in terms of safety, either should consult with the Agency's Safety and Health Officer.
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U.S. DEPARTMENT OF LABOR FLEXIPLACE PROGRAM Section 14: Employee Self-Certification Safety Checklist |
