Title Page
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Organisation or business name
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Owner name or site manager
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Phone Number
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Email address
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Conducted on
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Prepared by
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Premises address
Other information
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Australian Business Number (ABN)
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Provide a short overview of what your business or organisation does *
Workplace physical distancing measures
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You need to consider what measures are implemented to ensure staff and customers maintain appropriate physical distancing of 1.5 metres
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Have you provided education on physical distancing to staff? *
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Have you provided clear guidance on physical distancing to customers? *
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Can physical distancing be managed in staff and common areas? *
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Have you considered the use of technology to assist with physical distancing where possible (for example ordering online)? *
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Will physical distancing be managed as part of any delivery service? *
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Will physical distancing be managed when delivering or picking up goods? *
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List the measures you will use to manage physical distancing *
Hygiene measures
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You need to consider what measures are implemented to ensure staff and customers maintain appropriate hygiene within the business
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Have you provided education or information on COVID-19 hygiene protocols and practices to staff and volunteers? *
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Have you provided clear guidance on COVID-19 hygiene protocols and practices to customers? *
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Do you have adequate supplies of cleaning and sanitiser products? *
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Can your staff and customers wash or sanitise their hands regularly? *
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Have you identified high touch surfaces (for example door handles, service counters) and increased your regular cleaning schedule? *
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Do you have adequate waste management facilities including rubbish bins? *
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List the measures you will use to manage hygiene *
Monitoring and identification of unwell staff
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You need to consider what measures are implemented to ensure staff remain well at work.
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Have you provided education or information about COVID-19 transmission and symptoms to staff? *
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Do you have protocols for staff to not attend work if they are unwell? *
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Have you provided direction to staff to seek medical advice if they have symptoms of COVID-19? *
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List the measures you will use to manage the health of your staff *
Sign Off
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