Preparing for Home Working or Flexible Working

• Conducted on

  Date

• Prepared by

• Location
  Address

• Please provide your personal details below

• Employee Name

• Employee Role

• Department

• Line Report

• Date of Assessment

  Date

Your Personal Circumstances

• 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

• Please state your relationship to this person or persons

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

  Select NO, there would be no impact NO, provided I was based at Home To some extent - I could share childcare responsibilities YES, I would need to look after my child/children/relative Full Time I do Not have any dependents to Look after

  • NO, there would be no impact
  • NO, provided I was based at Home
  • To some extent - I could share childcare responsibilities
  • YES, I would need to look after my child/children/relative Full Time
  • I do Not have any dependents to Look after

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

  Yes

  No

• Briefly describe the areas of support you require. E.G. How to access the Shared Drive from a VPN?

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

  1 day

  1 week

  1 Month

  More than 1 month

  I wouldn't be affected

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

• Please provide the following details

• Address of the Property

• Location being assessed - E.G. Spare Room or Dining Room etc. etc.

• Proposed Number of Days to work at Home each week

• Which day or days would you NOT propose to work at Home

  Select Monday Tuesday Wednesday Thursday Friday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday

• Could you work from HOME without undue distraction?

  Yes

  No

• Is the workspace in the HOME capable of being secured so that work remains confidential where required? e.g. to comply with GDPR or Client Confidentiality

  Yes

  No

• Does your Mortgage Provider or Landlord require notice and authorisation under their agreements to enable you to work from Home?

  Select Yes No I own this property so no authority needed

  • Yes
  • No
  • I own this property so no authority needed

• Does your HOME Insurance cover homeworking activities and equipment?

  Yes

  No

• Do you know whether you need planning permission to work from home?

  Yes

  No

• Are you aware of the requirement to report incidents and near misses?

  Yes

  No

• Are you concerned in anyway about being isolated or a lack of contact with co-workers?

  Yes

  No

• Have you determined some “Keeping in touch" arrangements with co-workers and your Line Manger?

  Yes

  No

• What are these arrangements?

• Is any and all work equipment kept out of view?

  Yes

  No

• Is this equipment kept in a secure area with locks on entry doors when the building is empty?

  Yes

  No

• Are your security arrangements at the home in place and working?

  Yes

  No

• Briefly describe those arrangements. e.g. Property fitted with an Intruder Alarm and Locks on all doors and windows

• Do you have adequate fire safety equipment in the environment e.g. smoke detector, fire blanket?

  Yes

  No

• Do you have first aid equipment available in case of an accident?

  Yes

  No

• You MUST evidence all questions with Photographs to support your answers

• Is the lighting in the workspace suitable and sufficient?

  Yes

  No

• Is there a functional blind to reduce/increase light from the window?

  Yes

  No

• Is the floor free from boxes, wiring and other obstacles which may cause someone to trip?

  Yes

  No

• Are all surfaces free from sharp edges which could cause cuts?

  Yes

  No

• Is the storage of paper and other stationery away from sources of fire?

  Yes

  No

• Are the wiring and electrical sockets in good working order?

  Yes

  No

• Is there enough room to change position and vary movement?

  Yes

  No

• Is the workplace free from distracting equipment noise?

  Yes

  No

• Is the temperature comfortable to work in throughout the seasons?

  Yes

  No

• Is the area free from draughts?

  Yes

  No

• You MUST evidence all questions with Photographs to support your answers

Workstation

• What type of workstation are you proposing to use? e.g. A desk or dining table etc. etc.

• Is the work surface large enough for all the necessary equipment and documents etc. etc?

  Yes

  No

• Is the work surface stable?

  Yes

  No

• Are work surfaces free from glare and reflection?

  Yes

  No

• Can you comfortably reach all the equipment and papers you need to use?

  Yes

  No

• Is there sufficient space for thighs and knees?

  Yes

  No

• Is there space to stretch your legs?

  Yes

  No

• Is there enough support for hands and wrists?

  Yes

  No

• What type of Computer are you using on the workstation?

  Desktop Computer

  Laptop

  Tablet

• Is the software suitable for the task?

  Yes

  No

• Do you have sufficient training and knowledge in the use of the software?

  Yes

  No

Seating Arrangements

• What type of seating arrangement is in place?

• Is the chair/seat stable?

  Yes

  No

• Does the chair/seat swivel to give access to other areas of the workstation?

  Yes

  No

• If the chair/seat is fitted with armrests, can it be manoeuvred close enough to the work surface?

  Yes

  No

• Are the mechanisms for adjustments easy to operate from a sitting position?

  Yes

  No

• Is the chair’s height adjustable?

  Yes

  No

• Does the seat pad provide adequate support for thighs and buttocks?

  Yes

  No

• Does the chair provide support for the lower back?

  Yes

  No

• Does the backrest adjust in height and tilt?

  Yes

  No

• Are forearms horizontal and eyes at roughly the same height as the top of the Screen(s)?

  Yes

  No

• Are feet flat on the floor, without too much pressure from the seat on the backs of the legs?

  Yes

  No

• If feet do not touch the ground, do you have a footrest you can use?

  Yes

  No

• Is the chair adjusted correctly?

  Yes

  No

Display Screen(s)

• What is the Screen Configuration?

  Single Screen

  Multiple Screens

  Laptop Screen Only

• Is the screen free from glare and reflections from lights, windows or other images?

  Yes

  No

• Is the operator free from strong sources of light in the line of sight?

  Yes

  No

• Can the screen swivel?

  Yes

  No

• Can the screen tilt?

  Yes

  No

• Is the brightness adjustable?

  Yes

  No

• Is the contrast adjustable?

  Yes

  No

• Is the image stable, i.e. free of flicker and jitter?

  Yes

  No

• Are the characters clear and readable?

  Yes

  No

• Is the text size comfortable to read?

  Yes

  No

Keyboard and Mouse

• What type of Keyboard are you using on the workstation?

  Wired

  Wireless

  Part of the Laptop

• Is the keyboard in good working order?

  Yes

  No

• Does the keyboard tilt?

  Yes

  No

• Is the keyboard detachable/movable?

  Yes

  No

• Are the characters on the keys easily readable?

  Yes

  No

• Does the keyboard have a numeric pad?

  Yes

  No

• Is it possible to find a comfortable keying position?

  Yes

  No

• What type of Mouse are you using on the workstation?

  Wired

  Wireless

  Part of the Laptop

• Has a Mouse pad been provided for use with the Mouse

  Yes

  No

• Is the Mouse positioned close to the user?

  Yes

  No

• Is there support for the device user’s wrist and forearm?

  Yes

  No

• Does the device work smoothly at a speed that suits the user?

  Yes

  No

• Can you easily adjust software settings for speed and accuracy of pointer?

  Yes

  No

• Do you know to take regular breaks away from looking at a Display Screen?

  Yes

  No

• Do you know that you should NOT use a Smartphone continuously for more than an hour as part of your normal work?

  Yes

  No

• Do you know that you should NOT use a Smart Tablet continuously for more than an hour as part of your normal work?

  Yes

  No

• Do you suffer from aches or pains during normal work on any of the equipment?

  Yes

  No

• Do you suffer from eye strain?

  Yes

  No

• Have you had an eye and eye sight test within the last two years?

  Yes

  No

• Do you wear glasses as a result of an eye and eye sight test’s recommendations?

  Yes

  Not required to do so

  Not yet

• Do you know about your entitlement to FREE eye and eyesight testing?

  Yes

  No

• Please sign this declaration to say that to the best of your knowledge all the information you have provided is a true reflection of your Home Working arrangements and environment

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  Sign

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