COVID-19 Worksite Hazard Assessment Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Work Area/Department

  Select

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are partitions installed in break areas?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are meal/break times staggered?

  Yes

  No

  N/A

• Are employees allowed to ride in vehicles together?

  Yes

  No

  N/A

• Are employees teleworking when possible and applicable?

  Yes

  No

  N/A

• Do the employees come into contact with the public?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are doors touch-free?

  Yes

  No

  N/A

• Are faucets touch-free?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Facility Controls

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is signage posted limiting elevator capacity to 1 person?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Tools/Equipment

• Are employees allowed to share equipment?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Hazard Reporting

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

  Yes

  No

  N/A

• How should employees report COVID-19 workplace hazards?