Name

First Name

Last Name

Date Form Completed

YYYY

Job Title

Line Manager

Do you have any dependents living at home with you?

Yes

If you have dependants, to what extent would your ability to work be affected if they were not able to be in school?

Do you require any additional equipment to support you to work from home?

Yes

Please detail any specifics, if you answered 'yes' for the previous question.

When you are working from home, which description most closely resembles your best workstation set-up currently?

Do you feel able to easily and regularly communicate with your manager or colleagues?

From a wellbeing perspective, do you feel you need additional support?

Space for you to tell us anything else you think we need to know about your health and safety when working from home.

Thank you for submitting your response.

Any follow up required as a result of this questionnaire will be communicated with you.

For more information about how to sit comfortably and safely at your workstation: https://www.youtube.com/watch?v=c9ASq9xnXMU