Enclosure (3) to COMDTINST 12630.1
U.S. COAST GUARD
SELF-CERTIFICATION SAFETY CHECKLIST FOR
TELECOMMUTERS WORKING AT HOME
Name:
______________________________________________
Organization/Office:
______________________________________________
Geographical Location:
______________________________________________
Telephone:
______________________________________________
This checklist assesses the overall safety of the home work site. Each participant should read,
complete, sign, and date the self-certification safety checklist.
Address of home work site location:
________________________________________________________________________________
________________________________________________________________________________
Describe the designated home work area:
________________________________________________________________________________
________________________________________________________________________________
A. WORKPLACE ENVIRONMENT
1. Are temperature, noise, ventilation, and lighting
levels adequate to maintain your normal level of
job performance?
Yes
No
2. Are all stairs with four or more steps equipped
with handrails?
Yes
No
3. Does the electrical system conform to appropriate
local building codes?
Yes
No