Title Page

  • Conducted on

  • Prepared by

  • Location

Process & Procedures

  • Are relevant Covid-19 updates posted on staff noticeboards? Or have they been provided via internal communications?

  • Have your Supervisors been adequately trained on the implications of Covid-19?

  • Have you given staff members accurate information about ways to prevent the spread of infection?

  • Are your staff 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

Cleaning and Disinfecting Surfaces

  • Have you reviewed the cleaning measures to ensure that high risk contact areas and touch points are being regularly disinfected?

  • You should ensure that public surfaces such as counters, doorknobs, handles and light switches are regularly disinfected

  • Have you followed CDC guidance for cleaning and disinfecting hard surfaces?

  • For disinfection, diluted household bleach solutions, alcohol solutions with at least 70% alcohol, and most common EPA-registered household disinfectants should be effective.

  • Diluted household bleach solutions can be used on hard, non-porous surfaces. Ensure proper ventilation.

    Prepare a bleach solution by mixing:
    5 tablespoons (1/3rd cup) bleach per gallon of water or
    4 teaspoons bleach per quart of water

  • Have you followed CDC guidance for cleaning and disinfecting soft (porous) surfaces?

  • For soft (porous) surfaces such as carpeted floor, rugs, and drapes, remove visible contamination if present and clean with appropriate cleaners indicated for use on these surfaces.

    Use products with the EPA-approved emerging viral pathogens claims (list of products: https://www.americanchemistry.com/Novel-Coronavirus-Fighting-Products-List.pdf)

  • Have appropriate items been laundered following CDC guidance?

  • If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the warmest appropriate water setting for the items and then dry items completely.

    Do not shake dirty laundry; this minimize the possibility of dispersing virus through the air.

    Clean and disinfect hampers or other carts for transporting laundry according to guidance above for hard or soft surfaces.

Personal Protective Equipment (PPE) and Hand Hygiene

  • Are staff members following the CDC 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 staff members wearing disposable gloves and gowns for all tasks in the cleaning process, including handling trash?

  • Gloves and gowns should be removed carefully to avoid contamination of the wearer and the surrounding area. Be sure to clean hands after removing gloves.

    Cleaning staff should immediately report breaches in PPE (e.g., tear in gloves) or any potential exposures to their supervisor.

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

  • Do you have readily available access to Hand Sanitizer for all staff members?

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

  • An alcohol-based hand sanitizer that contains 60%-95% alcohol should be used. However, if hands are visibly dirty, always wash hands with soap and water.

Comments and Sign-off

  • Any comments or issues to report?

  • Add comments or issues here:

  • Name & Signature

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.