Homeworking Questionnaire (CIPD)

• Conducted on:

  Date

• Prepared by:

• Location:
  Address

Information

• The questions used in this template are based upon an excel template provided by the CIPD this is available at:
  
  https://www.cipd.co.uk/knowledge/fundamentals/relations/flexible-working/homeworking-questionnaire

Personal situation, vulnerabilities and dependencies

• Are you pregnant, or do you have a weakened immune system or a long-term medical condition such as diabetes, cancer, chronic lung disease or respiratory conditions such as asthma?

  Yes

  No

• Do you live with anyone who is pregnant, has a weakened immune system or a long term medical condition such as diabetes, cancer, chronic lung disease or respiratory conditions such as asthma?

  Yes

  No

• Do you have any regular caring responsibilities for children under the age of five, sick or elderly relatives?

  Yes

  No

• If schools/nurseries were to shut, would your ability to work be significantly affected?

  Select No Impact No, provided I was based at home To some extent – I could share childcare responsibilities with others Yes, I would need to look after my child/children full-time N/A

  • No Impact
  • No, provided I was based at home
  • To some extent – I could share childcare responsibilities with others
  • Yes, I would need to look after my child/children full-time
  • N/A

Working from home

• Do you need to use public transport to get to work?

  Yes

  No

• Do you currently work from home?

  Yes - Regularly

  Yes - Occasionally

  No

• What proportion of your job could be done working from home?

  All

  Most

  Some

  Very little

  None

• Do you have the necessary physical equipment (computer, phone, desk, papers etc) to work from home if this was needed?

  Yes

  No

• Please specify what else you require:

• Do you have the necessary applications or software to work from home if needed?

  Yes

  No

• Please specify what else you require:

• If you were to work from home, do you require remote access to the company network, information management system, or work-specific platform?

  Yes

  No

• Please specify what else you require:

• Do you have access to a reliable and secure internet connection?

  Yes

  No

• Are the computer and devices you would use for homeworking your own equipment?

  Yes

  No

• Please specify what these are:

  Yes

  No

• Are you able to use call forwarding to take calls at home or on your mobile?

  Yes

  No

• What additional equipment would you need to work from home for a sustained period of time? Consider any restrictions around equipment or space that needs to be shared in your household.

• Do you have the means to easily communicate with your manager or colleagues, to share progress and stay up to date with work projects?

  Yes

  No

• Please specify methods:

• Will you require additional training or support to work from home or to use any remote working systems?

  Yes

  No

• Please specify:

• For how long could you work from home before your work productivity is seriously affected?

  1 day

  1 week

  1 month

  More than 1 month

  Other (please specify)"

• Please specify:

• What business tasks would you be unable to perform from home?

Sign-off

• Name & Signature:

  Sign