This form is to be completed if telework is to be done from home. If a
telecenter or other location will be used instead, you do not need to
complete this form.

Employee has designated the following location as employee's home work
area:

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(Please specify room or area of residence)

##### A. Work Station Setup

1.  If in basement, will there be a problem with moisture? \_\_Yes \_\_
    No \_\_ N/A

2.  Separate from major family activity area? \_\_Yes \_\_ No \_\_ N/A

3.  Secure from pets and family members? \_\_Yes \_\_ No \_\_ N/A

4.  Background or distracting noise is minimal? \_\_Yes \_\_ No

> (television, other persons, outside traffic)

5.  Equipment not easily viewed from outside/external areas? \_\_Yes
    \_\_ No

6.  Office furniture and equipment ergonomically correct as

specified at
[[http://dohs.ors.od.nih.gov/ergonomics_home.htm]{.underline}](http://dohs.ors.od.nih.gov/ergonomics_home.htm)?
\_\_Yes \_\_ No

7.  Lighting: Directed behind or to the side of line of vision,

not in front or above it? \_\_Yes \_\_ No

8.  Storage: 2 or 4 drawer file drawers needed? \_\_Yes \_\_ No

9.  Supplies/resources close to desk? \_\_Yes \_\_ No

10. Does home office comply with lease/association agreement? \_\_Yes
    \_\_ No \_\_ N/A

#### B. Safety

> 1\. Safe exit path from work area? (recommended width = 36") \_\_Yes
> \_\_ No

2.  Evacuation plans established? \_\_Yes \_\_ No

3.  Smoke detector/alarm present and functional? \_\_Yes \_\_ No

4\. Fire extinguisher near work area? \_\_Yes \_\_ No

5\. First aid supplies adequate? \_\_Yes \_\_ No

6\. Extension/power cords secured and in safe condition? \_\_Yes \_\_ No

7.  Electrical outlets not overloaded? \_\_Yes \_\_ No

8.  No tripping hazards with electrical cords, loose rugs or carpet?
    \_\_Yes \_\_ No

9.  Equipment out of direct sunlight and away from heaters? \_\_Yes \_\_
    No

10. Air quality/ventilation adequate? \_\_Yes \_\_ No

11. Uncluttered work environment (amount of paper at reasonable levels)?
    \_\_Yes \_\_ No

12. Overhead shelves or cabinets not in hazardous locations? \_\_Yes
    \_\_ No

13. Property Insurance? \_\_Yes \_\_ No

> Homeowners \_\_
>
> Renters \_\_
>
> Liability \_\_

14. To the best of your knowledge, is the space free of material

> containing asbestos? \_\_Yes \_\_ No

15. A drinkable water supply available? \_\_Yes \_\_ No

16. Lavatory available with hot and cold running water? \_\_ Yes \_\_ No

17. All stairs with four or more steps equipped with hand rails? \_\_Yes
    \_\_ No \_\_ N/A

##### C. Security

1.  Locks on office door or file cabinet drawers? \_\_Yes \_\_ No \_\_
    N/A

2.  Power surge protection in use? \_\_Yes \_\_ No \_\_ N/A

3.  Protective or secure storage for floppy disks? \_\_Yes \_\_ No \_\_
    N/A

4.  Privacy for confidential phone conversations? \_\_Yes \_\_ No \_\_
    N/A

**Additional Comments/Suggestions:**
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By signing below, the employee certifies that this information is
correct and the manager certifies receipt of this document.

# Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Employee Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Manager Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_