COVID-19 Control Plan Template - MA

• Conducted on

  Date

• Prepared by

• Location
  Address

• All businesses in the state of MA must develop a written control plan outlining how its workplace will comply with the mandatory safety standards for operation in the COVID-19 reopening period. This template may be filled out to meet that requirement. Control plans do not need to be submitted for approval but must be kept on premise and made available in the case of an inspection or outbreak.
  All individually listed businesses must complete a control plan, even if the business is part of a larger corporation or entity.

Business Information

• Business name:

• Check if part of a larger corporation
• Address:
  Address

• Contact information (Owner/Manager):

• Contact information (HR representative), if applicable:

• Number of workers on-site:

Social Distancing

• Ensured that all persons, including employees, customers, and vendors remain at least six feet apart to the greatest extent possible, both inside and outside workplaces

  Yes

  No

  N/A

• Established protocols to ensure that employees can practice adequate social distancing

  Yes

  No

  N/A

• Posted signage for safe social distancing

  Yes

  No

  N/A

• Required face coverings or masks for all employees

  Yes

  No

  N/A

• Implemented additional procedures. (Please describe them on the note)

  Yes

  No

  N/A

Hygiene Protocols

• Provided hand washing capabilities throughout the workplace

  Yes

  No

  N/A

• Ensured frequent hand washing by employees and provided adequate supplies to do so

  Yes

  No

  N/A

• Provided regular sanitization of high touch areas, such as workstations, equipment, screens, doorknobs, restrooms throughout work site

  Yes

  No

  N/A

• Implemented additional procedures. (Please describe them on the note)

  Yes

  No

  N/A

Staffing & Operations

• Provided training for employees regarding the social distancing and hygiene protocols

  Yes

  No

  N/A

• Ensured employees who are displaying COVID-19-like symptoms do not report to work

  Yes

  No

  N/A

• Established a plan for employees getting ill from COVID-19 at work, and a return-to-work plan

  Yes

  No

  N/A

• Implemented additional procedures. (Please describe them on the note)

  Yes

  No

  N/A

Cleaning & Disinfecting

• Established and maintained cleaning protocols specific to the business

  Yes

  No

  N/A

• Ensured that when an active employee is diagnosed with COVID-19, cleaning and disinfecting is performed

  Yes

  No

  N/A

• Prepared to disinfect all common surfaces at intervals appropriate to said workplace

  Yes

  No

  N/A

• Implemented additional procedures. (Please describe them on the note)

  Yes

  No

  N/A

Completion

• Comments

• Name and Signature

  Sign