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