Employee Home Visit Form

EMPLOYEE HOME VISIT FORM

Employee Information

Position Information

Visit Details

Purpose of visit: Wellness check Workspace assessment Equipment delivery Compliance / verification Other:

Appointment scheduled: Yes No Scheduled date/time:

Date of visit:    Time in:    Time out:

Observations & Workspace Assessment

Primary work area location in home:

Ergonomics assessment: Chair adequate? Yes No    Desk adequate? Yes No

Internet connectivity adequate? Yes No    Mobile coverage adequate? Yes No

Follow-up Actions & Remediation

Responsible party for follow-up:    Target completion date:

Administrative History (HR Required Sections)

Employment History — Employer 1

Employment History — Employer 2

Education

Professional References

Reference 1

Reference 2

Reference 3

Legal Notices and Disclosures

At-Will Employment: Nothing in this document alters the at-will nature of employment. Employment may be terminated by either the employee or employer at any time, with or without cause or notice, except as otherwise provided by written agreement signed by an authorized representative of the company.

Equal Opportunity: The employer provides equal employment opportunities to all employees and applicants without regard to protected characteristics as defined by applicable law. This policy applies to all aspects of employment, including home visit procedures and evaluations.

Consent, Certification, and Authorization

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that the purpose of this visit has been explained to me and that the visit was conducted in a reasonable manner. I consent to the employer's representatives entering the specified portions of my residence for the limited purposes described above, subject to my right to deny access to private areas. I understand that observations and inventory recorded during this visit will be maintained in my personnel file for administrative use.

Authorization to Contact and Background Checks: I authorize the employer to contact prior employers and references listed in this form to verify employment history and credentials. I further authorize any background checks permitted by law as part of routine personnel administration related to this visit or my continued employment. I understand that any false statements or omissions may be grounds for disciplinary action, up to and including termination.

I received a copy of this completed form
I received notice that photographs or recordings may have been taken for documentation
I consent to this visit and the recording of non-sensitive observations

Additional Comments (Visitor)

Acknowledgment and Signature

Sign Now