Telecommuting Policies & Site Survey Template
Location of Proposed Home Office:
City: __________ State: ___ Zip: ____
1. Is the space well ventilated?
2. Is the space fairly quiet?
3. Do all stairways with four or more steps have handrails?
4. Are the fuses in the electrical panel properly labeled for each intended service?
5. Do the circuit breakers clearly indicate if they are ON or OFF?
6. Is all the electrical equipment free from recognized hazards that would cause physical harm such as frayed wires, bare
conductors, loose wires, etc.?
7. Are all the three pronged electrical outlets grounded?
8. Are aisles, doorways, and corners free from obstacles to permit visibility and movement?
9. Are the file cabinets and storage closets situated so drawers and doors will not open into through ways?
10. Are chairs sturdy and comfortable?
11. Is the proposed space crowded with furniture?
12. Are the phone lines, electrical cords secured under a desk or neatly situated along the baseboards?
13. Is the proposed office space well kept (neat and clean)?
14. Are the floor surfaces clean and level and free from excess wear?
15. Are any carpets well secured to the floor?
16. Is there a fire extinguisher in the home and is it easily accessible from the office space?
17. Is there a working smoke detector within hearing distance of the work space?
18. Does the employee agree to obtain an energy inspection of the home by the local utility company along with a fire and safety
inspection by the local fire department within thirty days of the signing of the Telecommuter Agreement?
19. Is this proposed workspace an acceptable home office space that will allow the employee to meet the
job requirements of Telecommuting.
Signature of Inspector
Print Name and Title