Fillable OFFICE OF HUMAN RESOURCES Telework Program Remote Workplace (Coppin State University)

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OFFICE OF HUMAN RESOURCES Telework Program Remote Workplace (Coppin State University)

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The OFFICE OF HUMAN RESOURCES Telework Program Remote Workplace (Coppin State University) form is 2 pages long and contains:

  • 2 signatures
  • 28 check-boxes
  • 11 other fields

Country of origin: US
File type: PDF

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1
OFFICE OF HUMAN RESOURCES
Telework Program
Remote Workplace Self-Certification Checklist
Name _____________________________________________ Empl. ID # ______________________
Title ____________________________________ Department ________________________________
Supervisor __________________________________________________________________________
This checklist is designed to assess the overall safety of your remote workplace and to ensure that
you have been properly prepared for teleworking. Upon completion, you should sign and return this
form to your supervisor and the Office of Human Resources at askhr@coppin.edu
.
I. Describe the workspace in your remote workplace:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
II. Telework Policy and Agreements
YES
NO
Have you read Coppin’s Teleworking Policy?
Have you discussed your Teleworker Work Schedule with your supervisor?
Have you completed the Teleworker Plan and discussed your performance
expectations with your supervisor?
Are you aware how to manage confidential and sensitive information outside of the
workplace?
How you completed a ‘laptop wellness check’ with the Information Technology
Division, if applicable?
Do you know how to access VPN, if applicable?
Please check
2
III. Workspace Environment
YES
NO
Is the workspace free of potential hazards that could cause physical harm (frayed or
loose wires, bare conductors, and uneven floor surfaces)?
Are electrical outlets grounded (3 pronged)? Are the phone lines, electrical cords,
and extension wires secured?
Are the rungs and legs, and wheels of the chair(s) sturdy?
Is the office space neat, clean, and free of obstructions and combustibles?
Is there adequate lighting for reading, reviewing work documents, and for use of the
computer?
Is a fire extinguisher easily accessible from the office space?
Is there a working smoke detector within hearing distance of the workspace?
Is the area free from distractions?
I certify that all information contained in this checklist is true and complete to the best of my
knowledge. I understand that any erroneous, misleading or fraudulent information is sufficient
grounds for my preclusion from teleworking and/or disciplinary action.
_________________________________________________ _________________________
Employee Signature Date
_________________________________________________ _________________________
Supervisor Signature Date
OHR –
Telework Program
V1.0 2020
Please check
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OFFICE OF HUMAN RESOURCES Telework Program Remote Workplace (Coppin State University)

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Completed 29 January 2021

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