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VISTA-Member-Teleservice-Application-Checklist 03.18.20 0 - TeleworkChecklist

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Country of origin: US
File type: PDF

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NAME:
VISTA PROJECT:
HOME ADDRESS AND PHONE NUMBER:
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. He or she
will , upon approval, submit the form to the State or Regional Office.
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
[
]
Computer Workstation (if applicable)
9. Is your back adequately supported by a backrest?
10. Are your feet on the floor or fully supported by a footrest?
11. Are you satisfied with the placement of your monitor and
keyboard?
12. Is it easy to read the text on your screen?
13. Is there space to rest the arms while not keying?
14. When keying, are your forearms close to parallel to the floor?
15. Are your wrists fairly straight when keying?
VISTA’s 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 employee’s home. No such inspection is required.
Supervisor’s 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 supervisor has inspected the employee’s home. No such inspection is required.
Teleservice is not authorized without this signature.
CNCS Representative’s Name (Print) Signature Date
2
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Completed 2 June 2020

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