Alternate Worksite Readiness Evaluation Form
Employee Information
Employee Name
Department
Position/Title
Supervisor Name
Date
Alternate Worksite Location
Address
Worksite Evaluation Checklist
Ergonomic workstation setup
Adequate privacy and quiet for work tasks
Reliable internet connection
Sufficient electrical outlets
Adequate lighting
Secure storage for sensitive information
Emergency procedures are understood
Comments/Notes
Employee Signature
Date
Supervisor Signature
Date