HCi takes your safety seriously, and as you’ve nominated that you’d like to do some work from home, we’d like you to do a quick self-inspection of your home work environment so that we can help you avoid workplace risk.

This inspection assumes that you’re going to be carrying out routine computer-based work (reading, writing, etc) as well as using basic office equipment (printer, stapler, etc).

Please print, complete, sign and fax/photograph this sheet back to us at

Note that until you have completed and returned this form, and received email approval from us, you are not permitted to work from home.

1 Basic details

Full name
Proposed work address
What room do you plan to work in?

2 Environment

Workstation, layout and equipment / Check against Officewise[1] /  OK or comments:
Lighting / Check against Officewise[2] /  OK or comments:
Noise / Environment is sufficiently quiet to allow you to work without suffering stress and/or hearing damage /  OK or comments:
Temperature / Environment is neither too hot nor too cold for your comfort /  OK or comments:
Trip hazards / No trip hazards (wires, rugs, boxes, pets) /  OK or comments:
Electrical / All electrical wiring properly maintained; earth leakage protection in place; outlets not overloaded; any equipment or extension cords or adapters are known to be safe /  OK or comments:
First aid / First aid supplies are available, and you or others in the premises are suitably trained and confident in their use /  OK or comments:

3 Work practices

Breaks / Take breaks at regular intervals, walk about for a few minutes every hour; set an alarm to remind you /  OK or comments:
Lifting / No requirement to lift or move heavy objects in order to work /  OK or comments:

4 Other hazards

Food and drink / Work area is segregated from cooking, cleaning products and food preparation areas and other heat, chemical and sharps hazards /  OK or comments:
Exits / Path to a safe exit is clear and known (eg in case of fire) /  OK or comments:
Medical / If alone in the building, able to raise emergency services or other help; no known medical conditions which might put you at risk if you are working alone /  OK or comments:
Fire / Smoke detectors fitted; fire extinguisher provided /  OK or comments:
Chemical / No dangerous chemicals present (asbestos, flammable materials, etc) /  OK or comments:
Other / No other risks which you are aware of /  OK or comments:

5 Signature

I warrant that all of the above information is true and correct.

(signed)

Date:

Complete, print, sign, scan/photograph and then email to

1

[1]http://www.vwa.vic.gov.au/forms-and-publications/forms-and-publications/officewise-a-guide-to-health-and-safety-in-the-office

[2]http://www.vwa.vic.gov.au/forms-and-publications/forms-and-publications/officewise-a-guide-to-health-and-safety-in-the-office