Title Page

  • Conducted on

  • Prepared by

  • Location
  • Work Area/Department

  • The controls and activities described below are components of the MID COVID Prevention Plan and incorporate recommendations from the CDC and Cal/OSHA. Evaluation of potential workplace exposure will be with respect to all persons at the workplace or who may enter the workplace, including co-workers, employees of other entities, members of the public, customers or vendors, and independent contractors.

Social Distancing

  • Is the workspace configured so that employees can work and maintain 6 feet of physical space between them?

  • Are there any job tasks that do not allow employees to maintain 6 feet of physical space between them?

  • Which tasks do not allow employees to maintain 6 feet of physical space between them?

  • Is the workspace configured so that employees are not facing each other when possible?

  • Are chairs spaced at least 6 feet apart in break or meeting rooms?

  • Are additional break areas identified to allow employees to maintain 6 feet of distance during break times? eg. additional training/conference rooms, outdoor tables, etc.

  • Are physical barriers, such as cubicle partitions or plexiglass installed between work spaces when 6 feet of distancing is not possible?

  • Are partitions installed in break areas?

  • Are visual cues such as signs, floor markings, etc. in place to remind employees to maintain distance?

  • Are employees scheduled to stagger start/stop times to help maintain social distancing?

  • Are meal/break times staggered?

  • Are employees allowed to ride in vehicles together?

  • Are employees teleworking when possible and applicable?

  • Do the employees come into contact with the public?

  • What type of interaction is done with members of the public?

  • What protective devices are in place to put a physical distance/barrier between the employee and member of the public?

  • Identify the areas that employees may congregate, such as hallways, break rooms, etc. in this work area.

Hand Hygiene

  • Are hand washing facilities available for employee use?

  • Are hand sanitizing stations available in multiple locations with at least 60% alcohol hand sanitizer?

  • Are doors touch-free?

  • Are faucets touch-free?

  • Are visual cues such as signs in place to encourage employees to wash their hands?

Facility Controls

  • Is signage posted at employee entrances reminding employees to complete a wellness self-assessment?

  • Is signage posted at employee entrances reminding sick workers to stay home?

  • Is signage posted limiting elevator capacity to 1 person?

  • Is there a regular cleaning schedule set for frequently touched surfaces?

  • Are cleaning supplies available for employee use near frequently touched surfaces?

  • Is water available to employees to eliminate the need for use of drinking fountains?

  • Is building ventilation being altered to provide additional fresh air and circulation within the building when possible?


  • Are employees allowed to share equipment?

  • Which tools/equipment are being shared?

  • What protective measures are in place to clean/disinfect tools/equipment between users?

  • Are face coverings made available to employees?

  • What is the process for employees to get additional face coverings throughout the day?

  • Is hand sanitizer available for employee work areas/desks?

  • What is the process for employees to acquire hand sanitizer for his/her work area?

Meetings/Training/Work Procedures

  • Are phone calls/emails/web-meetings being held instead of in-person meetings when possible?

  • Have the employees completed training about COVID-19 hazards and prevention in the workplace?

Hazard Reporting

  • Are employees able to report COVID-19 workplace hazards?

  • How should employees report COVID-19 workplace hazards?

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.