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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Public Health registration number (if applicable)
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Australian Business Number (ABN)
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Type of personal service premises *
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 clients? *
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During stage 2, will all facial treatments be removed from your menu? *
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Do you have protocols in place to ensure clients stay for 2 hours or less? *
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Are you managing physical distancing when picking up goods or having goods delivered? *
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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 clients maintain appropriate hygiene within the business.
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Can your staff and clients wash or sanitise their hands regularly? *
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Have you provided education on COVID-19 hygiene protocols and practices to staff? *
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Have you provided information on COVID-19 hygiene protocols and practices to clients? *
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Do you have adequate supplies of cleaning and sanitiser products? *
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Have you identified high touch surfaces (for example door handles, service counters, equipment) 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 employees 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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Do you have protocols for notifying health authorities of suspect COVID-19 cases? *
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List the measures you will use to manage the health of your staff
Sign Off
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Prepared by