Employee Home Assessment Form

EMPLOYEE HOME ASSESSMENT FORM

This Employee Home Assessment Form documents the employee's remote work environment, safety and security conditions, company property issued for use at the employee's residence, and the employee's acknowledgement of responsibilities. Information provided is subject to the employer's workplace safety and asset management policies. Completion of this form does not modify at-will employment status unless expressly set forth in a separate written agreement.

Personal Information

Position Information

Employment Start Date:

Employment History

Most Recent Employer

Dates Employed:

Prior Employer

Dates Employed:

Education

Graduation Date:

Professional References

Reference 1

Reference 2

Reference 3

Home Workspace Assessment

Lighting: Natural Artificial Glare present

Ergonomics Checklist

Adjustable chair with lumbar support
Monitor positioned at or slightly below eye level
Keyboard and mouse at elbow height with wrists neutral
Footrest available if feet do not rest flat on floor
Frequent short breaks and stretch practices in place

Electrical & Fire Safety

Smoke detector present and functional
Extension cords in use (note location and condition below)
Surge protector/power strip present and in good condition

Network & Data Security

I will connect to company systems only via company-approved VPN or secure connection
Home network secured with strong password and encryption
I will use company-managed devices for work-related access where required
Antivirus and device encryption are installed on my work devices

Equipment Inventory (Company Property)

Check items issued to employee and record identifying tag or model information where applicable.

Keyboard Mouse Headset Chair

Emergency Procedures & Contacts

Legal Disclosures & Employee Certifications

At-Will Employment: Employment with the employer is at-will, which means either the employee or the employer may terminate the employment relationship at any time, with or without cause or advance notice, except as otherwise provided by law or a written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer is an equal opportunity employer and does not discriminate on the basis of protected characteristics as defined by applicable law. The employee acknowledges the employer's nondiscrimination policies and reporting channels for concerns.

Inspection and Access: By signing below, the employee authorizes the employer to conduct reasonable inspections of the listed workspace and company-owned equipment at the employee's residence upon prior notice or as otherwise permitted by applicable law. Inspections will be limited to the workspace and equipment listed in this form and will be conducted in a manner that respects employee privacy.

Background and Reference Check Authorization: The employee authorizes the employer to contact prior employers and professional references provided herein and to conduct background checks as permitted by law for employment-related purposes. The employee certifies that the information provided in this form is true and complete to the best of their knowledge.

Certification: I certify that all information provided on this Employee Home Assessment Form is true, complete and accurate. I agree to maintain a safe and secure remote work environment, to follow employer policies for equipment use and data security, and to promptly notify my manager of any material changes to my workspace or contact information.

I consent to reasonable inspection of my designated workspace and company equipment as described above.

I authorize the employer to contact the references and past employers listed and to obtain background checks as permitted by law.

Applicant Certification: I certify that the information provided in this form is accurate and complete. I understand that falsification or omission of material information may result in disciplinary action, up to and including termination of employment.

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