Fillable AmeriCorps VISTA Teleservice Request Form (Corporation for National & Community Service)

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AmeriCorps VISTA Teleservice Request Form (Corporation for National & Community Service)

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The AmeriCorps VISTA Teleservice Request Form (Corporation for National & Community Service) form is 2 pages long and contains:

  • 3 signatures
  • 0 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Corporation for National & Community Service

BROWSE CORPORATION FOR NATIONAL & COMMUNITY SERVICE (DC) FORMS

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AmeriCorps VISTA Teleservice Request Form
The following checklist is to assess the safety of teleservice arrangement and serves as the
request form. Please complete the form and submit it to your VISTA supervisor. The supervisor
will, upon approval, sign and submit the form to the CNCS Regional Office.
* Find your NSPID on the Member Home screen in my.americorps.gov.
CHECKLIST
Home Environment
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
NAME:
NSPID*:
VISTA PROJECT:
HOME ADDRESS AND PHONE NUMBER:
Computer Workstation
9. Is your back adequately supported by a backrest?
YES NO
10. Are your feet on the floor or fully supported by a footrest?
YES NO
11. Are you satisfied with the placement of your monitor and keyboard?
YES NO
12. Is it easy to read the text on your screen?
YES NO
13. Is there space to rest the arms while not keying?
YES NO
14. When keying, are your forearms close to parallel to the floor?
YES NO
15. Are your wrists fairly straight when keying?
YES NO
VISTA Member Name (Print) Signature Date
Supervisor’s signature indicates his or her receipt of this form and approval of the teleservice request; it
does not signify that the supervisor has inspected the member’s home. No such inspection is required.
Supervisor Name (Print) Signature Date
The CNCS representative’s signature indicates his or her receipt of this form and approval of the
teleservice request; it does not signify that the representative has inspected the member’s home. No
such inspection is required. Teleservice is not authorized without this signature.
CNCS Representative Name (Print) Signature Date
2
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AmeriCorps VISTA Teleservice Request Form (Corporation for National & Community Service)

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Completed 15 March 2021

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