Title Page

  • Conducted on

  • Prepared by

  • Shift

  • Day in rotation

  • Crew

  • Department

  • Area inspected

Process & Procedures

  • Are your crew members aware of the symptoms of Covid-19?

  • Symptoms of Covid-19:

    The main symptoms to look out for are:

    1. A cough
    2. A high temperature (100.4° F or greater)
    3. A shortness of breath

  • Is there an established cleaning schedule of the work area

Cleaning and Disinfecting Surfaces

  • Are the high risk contact areas and touch points being regularly disinfected? (tables, chairs, counters, doorknobs, handles and light switches)

  • Are cleaning solutions being used of diluted household bleach, or alcohol solutions with at least 70% alcohol?

  • Are the bathrooms cleaned and disinfected regularly?

Personal Protective Equipment (PPE) and Hand Hygiene

  • Do all wash areas have antibacterial soap accessible?

  • Are employees following the recommended hand washing protocol?

  • Follow these five steps every time.

    1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
    2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.
    3. Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.
    4. Rinse your hands well under clean, running water.
    5. Dry your hands using a clean towel or air dry them.

  • Are employees wearing disposable gloves for all tasks in the cleaning process, including handling trash?

  • Are employees following normal preventive actions while at work including cleaning hands and avoiding touching eyes, nose, or mouth with unwashed hands?

  • Do all employees have access to Hand Sanitizer?

  • Does the Hand Sanitizer contain at least 60% alcohol content?


  • Are PK units cleaned and disinfected regularly? (Daily if shared and weekly if assigned)

  • Are transport vehicles cleaned and disinfected after each use?

Social Distancing

  • Are employees and crews practicing good social distancing? (6 foot spacing)

  • Are zoom, call in and web based meetings being utilized?

  • Are group meetings, and training practicing aggressive social distancing? (10 or less)

Comments and Sign-off

  • Please add before and after photos

  • Any comments or issues to report?

  • Add comments or issues here:

  • Name & Signature

  • Department Head

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.