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Self-Certification Safety Checklist
Ft Gordon Telework Program

The following checklist is designed to assess the overall safety of the alternate worksite. 
The participating employee should complete the checklist, sign and date it, and return
it to his or her Supervisor (and retain a copy for his or her own records).

 1.  Are temperature, noise, ventilation, and lighting             Yes [  ]  No [  ]
levels adequate for maintaining your normal level
of job performance?

 2.  Is all electrical equipment free of recognized                 Yes [  ]  No [  ]
hazards that would cause physical harm (frayed
wires, bare conductors, loose wires or fixtures,
exposed wiring on the ceiling  or walls)?

 3.  Will the building’s electrical system permit the                Yes [  ]  No [  ]
grounding of electrical equipment (a three-prong
receptacle)?

4.  Are aisles, doorways, and corners free of                       Yes [  ]  No [  ]
obstructions to permit visibility and movement?

 5.  Are file cabinets and storage closets arranged so             Yes [  ]  No [  ]
drawers and doors do not enter into walkways?

 6.  Are phone lines, electrical cords, and  surge                     Yes [  ]  No [  ]
protectors secured under a desk or alongside a
baseboard?

 Employee’sSignature______________  Date__________

 NAME: ___________________________________________COMPONENT:  Army

 POSITION: Title, PP-SER-GR

 ALTERNATIVE WORKSITE TELEPHONE:  (XXX)XXX-XXXX

 Supervisor’s Name:  _______________________________________

PLEASE RETURN A COPY OF THIS FORM TO YOUR
FLEXIPLACE COORDINATOR

10/12/2010                                Back to Telework Page                         Back to CPAC