Employee Checklist Template - Free Download | Page 2
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SAMPLE CHECKLIST AND
EMPLOYEE CERTIFICATION FORM
*Sample Checklist was taken from other employers’ telecommuting material. 2
12. Will the building’s electrical system permit the grounding of electrical
equipment YES NO
13. Are aisles, doorways, and corners free of obstructions to permit visibility and
movement YES NO
14. Are file cabinets and storage closets arranged so drawers and doors do not
open into walkways YES NO
15. Do chairs have any loose casters (wheels) Are the rungs and legs of chairs
sturdy YES NO
16. Is the work area overly furnished YES NO
17. Are the phone lines, electrical cords, and extension wires secured under a
desk or alongside a baseboard YES NO
18. Is the office space neat, clean and free of excessive amounts of combus-
tibles YES NO
19. Are floor surfaces clean, dry, level, and free of worn or frayed seams YES NO
20. Are carpets well-secured to the floor and free of frayed or worn seams YES NO
Employee Signature Date
Supervisor or Designated Agency Representative Date
source: resources.dhrm.virginia.gov
