* Find your NSPID on the Member Home screen in my.americorps.gov.

VISTA Teleservice & Virtual Service Site

Request & Agreement Form

The following checklist is to assess the safety of a teleservice or virtual service site 

arrangement and serves as the agreement form. VISTA Members: Please complete 

the form and submit it to your VISTA site supervisor for review and approval. Site 

Supervisors: Please review, once the request is approved or disapproved, please 

submit the form to the VISTA sponsor. VISTA Sponsors: Sponsors must 

acknowledge and maintain access to the record of all forms in accordance with 

record retention policies. 

VISTA’s NAME: NSPID*:

VISTA Assignment Description Title:

VISTA’s Email Address while serving:

VISTA’s Phone number while serving:

VISTA Project Sponsor Name:

Site Name (if different from sponsor):

Service Site Address:

Site Supervisor Name:

Site Supervisor Phone #: 

Teleservice / Virtual Service Site Address: Type of Request: 

 Teleservice Request

o Full Time Request (5 days

per week)

o Less than 5 days per week

Request

 Virtual Service Site Request

Site Supervisor Email: 
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CHECKLIST

Teleservice and Virtual Service Site Environment

To be completed by the AmeriCorps VISTA member, leader, or summer 

associate: 

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. 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 ☐

4. Are aisles, doorways, and corners free of obstructions to

permit visibility and movement?

YES ☐ NO ☐

5. Are file cabinets and storage closets arranged so

drawers and doors do not open into walkways?

YES ☐ NO ☐

6. Are the phone lines, electrical cords, and extension wires

secured under a desk or alongside a baseboard?

YES ☐ NO ☐

7. Is the office space neat, clean, and free of excessive

amounts of combustibles?

YES ☐ NO ☐

8. Are floor surfaces clean, dry, level, and free of worn

or frayed seams?

YES ☐ NO ☐

9. Is there enough light for reading? YES ☐ NO ☐

10. Is your service location free of safety hazards? YES ☐ NO ☐

Computer Workstation 

To be completed by the AmeriCorps VISTA member, leader, or summer 

associate: 

11. Is your back adequately supported by a backrest? YES ☐ NO ☐

12. Are your feet on the floor or fully supported by a footrest? YES ☐ NO ☐

13. Are you satisfied with the placement of your monitor and

keyboard?

YES ☐ NO ☐

14. Is it easy to read the text on your screen? YES ☐ NO ☐
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15. Is the screen free from noticeable glare? YES ☐ NO ☐

16. Is the top of the screen eye level? YES ☐ NO ☐

17. Do you have enough leg room at your desk? YES ☐ NO ☐

18. Is there space to rest the arms while not typing? YES ☐ NO ☐

19. When typing, are your forearms close to parallel to the floor? YES ☐ NO ☐

20. Are your wrists fairly straight when typing? YES ☐ NO ☐

VISTA’s Agreement:

I have read and understand the AmeriCorps VISTA Teleservice and Virtual Service Site Policy. I

agree to abide by the terms and conditions. I further agree that while serving from a teleservice / 

virtual service site location I will abide by all applicable VISTA policies and procedures. I

understand that failure to abide by these polices and rules may result in administrative action 

against me, including possible removal from VISTA service. If I have questions concerning my 

teleservice or virtual service site agreement I will contact my site supervisor immediately for 

assistance.

I further understand and agree to my sponsor / site policies and procedures regarding proper 

use of equipment and resources provide to me. I understand all equipment and resources issued 

to me should be returned to my sponsor / site when I leave VISTA service. 

VISTA’s Name (Print) Signature Date

VISTA Additional Notes / Comments Section:
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SUPERVISOR DECISION: 

Approved ☐ Disapproved ☐

Supervisor’s signature indicates the receipt and review of this form and the approval or 

disapproval of the teleservice or virtual service site request; it does not signify that the 

supervisor has inspected the VISTA’s alternative work address. No such inspection is required.

Supervisor Name (Print) Signature Date

VISTA SPONSOR RECORDS: 

Date Acknowledged by sponsor: __________________________ 

Sponsor Additional Comments: 

Effective Date: 

Supervisor Additional Notes / Comments Section: 

Please note that if the request is disapproved, an explanation is required. If the teleservice request 

type is “Less than 5 days a week” please include details as to how often VISTAs will teleserve.