COVID Risk Assessment Tool - Workplace Infection Control

• Date of Assessment

  Date
• Facility Location
  Address

• Prepared by

Assessment Details

• Type of assessment

  Off-site

  On-site

  Other

• Specify

Facility information

• Facility name:

• Type of industry (e.g., elementary school, clothing manufacturing, restaurant, grocery store)

• Type of site/facility (any additional descriptive information, e.g., Industry = clothing manufacturing, oil and gas; Type = shoe production, neurology wing, gas pipeline)

• Name(s) of employers and contracting companies who have workers on-site

• Total number of employees who work at this site

• Total number of contractors who work at this site

• Number of production workers (if applicable)

• Number of production contractors (if applicable)

• Number of office employees (if applicable)

• Number of office contractors (if applicable)

• Number and types of shifts

• Shift start, shift end, and break times:

• Number of breaks and length of breaks:

• Names of departments or work areas in facility:

Workforce diversity

• Primary languages spoken by workforce:

  English

  Spanish

• % of workforce that speak/understand and read

• Describe others (record percentage of workers that speak each language):

• Any other cultural factors that should be considered in prevention recommendations [Optional]:

Employer-sponsored transportation

• Employer-sponsored transportation to or during work?

  Yes, entire workforce

  Yes, some of the workforce

  No

  N/A

• What types of transportation? (e.g., ride-share vans or shuttle vehicles, car-pools, and public transportation)?

• Are workers able to maintain social distancing during transportation to work?

  Yes

  No

  N/A

• Are workers required to wear cloth face coverings during employer-sponsored transportation?

  Yes

  No

  N/A

• Are workers encouraged to wear cloth face coverings during employer-sponsored transportation?

  Yes

  No

  N/A

• Additional comments/observations:

Group transportation to work that is not sponsored by employer

• Group transportation to work that is not sponsored by employer

  Yes, entire workforce

  Yes, some of the workforce

  No

  N/A

• What types of transportation? (e.g., ride-share vans or shuttle vehicles, car-pools, and public transportation)?

• Additional comments/observations:

Employer-sponsored housing

• Employer-sponsored housing for workers?

  Yes, entire workforce

  Yes, some of the workforce

  No

  N/A

• Do employees live together in group housing that is not employer-sponsored?

  Yes

  No

  Unkown

• Additional comments/observations:

Other workforce characteristics that might be relevant to infectious disease transmission

• Do workers work in other facilities of the same company?

  Yes

  No

  Unkown

• Which facilities?

• Do any workers come to the facility from work release programs?

  Yes

  No

  Unkown

• Job share or work exchange programs?

  Yes

  No

  Unkown

• Additional comments/observations:

Union information

• Union representation

  Yes, entire workforce

  Yes, some of the workforce

  No

  N/A

• Name of union(s) and point(s) of contact for each

Federal, State, Local agency information

• Name and contact information of important regulatory agency official(s) for industry [if any, e.g., OSHA, USDA]

• Is there any OSHA activity at the facility?

  Yes

  No

  Unkown

• Additional local and/or state public health authorities and other stakeholder contact information:

COVID-19 Workplace Health and Safety Plan

• Workplace COVID-19 coordinators identified

  Yes

  No

• Who are the coordinators? (include their contact information and their backgrounds)

• Plans have been developed to continue essential functions with higher than usual absenteeism

  Yes

  No

• What are those plans?

• Mechanism for monitoring and tracking absenteeism

  Yes

  No

• Describe

• Standard operating procedures for cleaning and disinfection have been modified as necessary for COVID-19

  Yes

  No

• Leave policies are flexible, non-punitive, and encourage ill employees and employees who have been in close contact with confirmed or suspected COVID-19 cases to stay home

  Yes

  No

• What is the policy?

• How would taking leave affect income?

• Has the policy been consistently communicated to employees?

  Yes

  No

• Coordination with occupational safety, health, or medical professionals

  Yes

  No

• Does the facility have an on-site occupational safety and health services?

  Yes

  No

• If no on-site services are provided, does the facility refer to or have a contract with off-site occupational safety and health services?

  Yes

  No

• What role, if any, are these services playing in health screening, referral for further evaluation, testing, and other policies?

• Collaboration with local and/or state public health authorities and other stakeholders

  Yes

  No

• Consulted with local and/or state public health authorities

  Yes

  No

• Name and contact information for local and/or state contacts

• Pre-shift employee health screening has been considered or implemented

  Yes, considered

  Yes, implemented

  No

• Does pre-shift employee health screening include:

• Verbal questions about symptoms?

  Yes, considered

  Yes, implemented

  No

• Written questions about symptoms?

  Yes, considered

  Yes, implemented

  No

• Measurement of body temperature?

  Yes, considered

  Yes, implemented

  No

• Visitor (includes delivery workers)/customer/client health screening has been considered or implemented

  Yes, considered

  Yes, implemented

  No

• Does visitor/customer/client health screening include:

• Verbal questions about symptoms?

  Yes, considered

  Yes, implemented

  No

• Written questions about symptoms?

  Yes, considered

  Yes, implemented

  No

• Measurement of body temperature?

  Yes, considered

  Yes, implemented

  No

• Policies in place for managing workers with potential exposure to COVID-19

  Yes

  No

• What are the policies (please describe)?

  Select • Self-quarantine • Criteria for returning to work • Other

  • • Self-quarantine
  • • Criteria for returning to work
  • • Other

• Specify

• Policies for managing employees with symptoms

  Yes

  No

• What are the procedures for an employee to report symptoms before or at work?

• Policies for managing workers with confirmed or suspected COVID-19 or COVID-19 positive test result

  Yes

  No

• What are return-to-work criteria for workers with COVID-19 (e.g., symptom-based, time-based, or test-based)?

Workstations, production lines or areas, and other work areas (including cash register, food prep area, sales floor, warehouse, shipping and receiving, mailroom, and reception):

• Is there ability to maintain social distancing ≥6 feet?

  Yes

  No

• Does this vary by department or work area?

  Yes

  No

• Are workers, visitors, customers, or clients facing each other?

  Yes

  No

• Can workstation alignment allow for worker, visitor, customer, or client separation (≥6 feet)?

  Yes

  No

• Are physical barriers such as partitions (e.g., stainless steel, plexiglass, plastic strip curtains) in use to separate workers and visitor/customers/clients?

  Yes

  No

• Are these barriers being disinfected?

  Yes

  No

• How?

Other areas where workers, visitors, customers, or clients may congregate (including health screening area, entrances and exits, clock-in/out areas, uniform and equipment pickup area, PPE donning and doffing areas, hallways, break areas, dining areas/cafeteria, locker rooms, restrooms, smoking areas, and parking lots):

• Is there ability to maintain social distancing in these areas?

  Yes

  No

• Why not?

• Are physical barriers such as partitions (e.g., stainless steel, plexiglass, plastic strip curtains) in use to separate workers and visitor/customers/clients?

  Yes

  No

• Are these barriers being disinfected?

  Yes

  No

• How?

• Has the number of tables in lunch or break areas been decreased?

  Yes

  No

• Are other building spaces (e.g., conference rooms) in use for overflow?

  Yes

  No

• Are tents being added to be used for overflow?

  Yes

  No

• Is the number of workers, visitors, or customers/clients in a space at one time being limited?

  Yes

  No

• Are clock in/out stations touch-free?

  Yes

  No

• Are workers able to safely and easily access potable water in the workplace?

  Yes

  No

• Visual cues to maintain social distancing

  Yes

  No

• What methods (e.g., floor markings, signs) are used?

• Handwashing and hand sanitizer stations

  Yes

  No

• Are handwashing stations and/or hand sanitizers (ideally touchless) placed in multiple locations?

  Yes

  No

• Where are they located (e.g., all entrances, common areas)?

  Yes

  No

• Are they touch-free?

  Yes

  No

• Are they easily accessible?

  Yes

  No

• Are all stations functioning and stocked with adequate supplies (e.g., sanitizer, soap, single use paper towels)?

  Yes

  No

• Is there a mechanism to report depleted supplies?

  Yes

  No

• Are workers aware of how to report?

  Yes

  No

  N/A

• Is there ability to maintain social distancing?

  Yes

  No

• Is additional time allotted to accommodate more frequent and thorough handwashing for each shift, during the shift, and/or between shifts?

  Yes

  No

• What type/s of ventilation is/are in place (general or local)?

• Have personal cooling fans been eliminated?

  Yes

  No

• If pedestal fans or hard mounted fans are used, minimize fans blowing air from one worker directly towards another worker.

• What steps are being taken to prevent heat hazards?

Food production areas (if applicable)

• What cleaning and disinfection agents are used?

• Are cleaning and disinfection agents consistent with USDA and EPA recommendations?

  Yes

  No

• What is the frequency of cleaning and disinfection?

• Are products being applied at the appropriate concentration?

  Yes

  No

• Are products being applied for the appropriate contact time?

  Yes

  No

Non-food production areas

• What cleaning and disinfection agents are used?

  Yes

  No

• Are they consistent with EPA List N recommendations?

  Yes

  No

• What is the frequency of cleaning and disinfection?

• Are products being applied at the appropriate concentration?

  Yes

  No

• Are products being applied for the appropriate contact time?

  Yes

  No

Targeted and more frequent cleaning of high priority surfaces including common areas, frequently touched surfaces, and physical barriers (if present)

• What surfaces are receiving additional cleaning and disinfection?

• What is the schedule for this cleaning?

• Are products being applied at the appropriate concentration?

  Yes

  No

• Are products being applied for the appropriate contact time?

  Yes

  No

• Are shared equipment and materials being cleaned and disinfected between use by each worker?

  Yes

  No

• What is the schedule for this cleaning?

• Are there cleaning and disinfecting procedures conducted between visitor/customers/clients?

  Yes

  No

• What are the procedures?

Enhanced cleaning and disinfection after persons with suspected or confirmed COVID-19 have been in the facility

• What policies and procedures are in place?

• Hazard assessment performed for cleaning and disinfection tasks

  Yes

  No

• Are protections in place to protect workers who perform cleaning and disinfection tasks from chemical hazards posed by disinfectants?

  Yes

  No

• Are they wearing PPE appropriate for these tasks?

  Yes

  No

Pre-shift employee/visitor health screening

• Is screening completed prior to entry into<br>the facility?

  Yes

  No

• Does screening include every person prior to building entry (including visitors/customers/clients and employees who arrive early or late or through other entrances)?

  Yes

  No

• Who performs the screening?

• Have screeners been appropriately trained?

  Yes

  No

• Are protections in place for the screeners?

  Yes

  No

• Social distancing?

  Yes

  No

• PPE?

  Yes

  No

• Barriers/partitions?

  Yes

  No

• PPE?

  Yes

  No

• What information is assessed?

• Are symptoms asked?

  Yes

  No

• Specify

• Are other questions asked?

  Yes

  No

• Specify

• Are temperatures being checked?

  Yes

  No

• How?

• Is social distancing between individuals awaiting screening being maintained during the process?

  Yes

  No

• How are employees who screen affirmatively managed?

• Is secondary screening done for those with fever or reported symptoms?

  Yes

  No

• What does it include?

• Who performs it?

• Where is it done?

• Is a referral process in place that will direct employees with signs or symptoms of COVID-19- like illness (CLI) to further assessment? If yes, please describe.

  Yes

  No

• Describe

• Are privacy practices in place, wherever possible?

  Yes

  No

• Is confidentiality maintained as required by the Americans with Disabilities Act (ADA)?

  Yes

  No

• Are physical distancing coaches being used?

  Yes

  No

• Are they effective?

  Yes

  No

Training and communication

• What is/are the mode(s) of delivery (e.g., online, written materials, beginning of shift updates)?

• What topics are covered?

• What languages are used?

• Are interpreters needed?

  Yes

  No

  N/A

• Who are they?

• Is there any signage?

  Yes

  No

• Where is it placed?

• What topics are covered?

• Is PPE required for usual job duties (required prior to COVID-19 pandemic)?

  Select Yes, at least some PPE was required prior to COVID-19 No, PPE was not required prior to COVID-19

  • Yes, at least some PPE was required prior to COVID-19
  • No, PPE was not required prior to COVID-19

• What types of PPE (e.g., disposable vs reusable, material, style) are required for which job tasks?

• Eye protection:

  Required

  Not Required

• Type or style (e.g. goggles, face shield, safety glasses)?

• Gloves:

  Required

  Not Required

• Type?

• Gown/coveralls/apron:

  Required

  Not Required

• Type?

• Facemask:

  Required

  Not Required

• Other facial covering:

  Required

  Not Required

• Type (e.g., face shield)?

• Respirator:

  Required

  Not Required

• Type?

• Other

• Is PPE provided by the employer?

  Yes

  No

• Are there challenges in sourcing PPE?

  Yes

  No

• Is PPE required specifically for COVID-19 prevention?

  Select Yes, PPE is now required specifically to prevent COVID-19 No, PPE is not required specifically to prevent COVID-19

  • Yes, PPE is now required specifically to prevent COVID-19
  • No, PPE is not required specifically to prevent COVID-19

• Eye protection:

  Required

  Not Required

• Type or style (e.g. goggles, face shield, safety glasses)?

• Gloves:

  Required

  Not Required

• Type?

• Gown/coveralls/apron:

  Required

  Not Required

• Type?

• Facemask:

  Required

  Not Required

• Other facial covering:

  Required

  Not Required

• Type (e.g., face shield)?

• Respirator:

  Required

  Not Required

• Type?

• Other

• Is PPE being used more than once (re-used)?

  Yes

  No

  N/A

• Is PPE designed to be re-used or is it being re-used in the setting of optimization due to decreased supply?

  Select Yes, designed to be re-used. No, being re-used due to decreased supply.

  • Yes, designed to be re-used.
  • No, being re-used due to decreased supply.

• How is reusable PPE being cleaned and disinfected?

  Yes

  No

• How often is reusable PPE being cleaned and disinfected?

• Is reusable PPE stored in a clean location at the facility (not taken home) when not in use?

  Yes

  No

• Is PPE provided by the employer?

  Yes

  No

• Are there challenges in sourcing PPE?

  Yes

  No

Face covering use (for source control)

• Are workers required to wear face coverings?

  Yes

  No

• In which parts of the facility are they being used?

• What materials are allowed for this industry?

  Select Cloth Other than cloth Both Cloth and Other than cloth

  • Cloth
  • Other than cloth
  • Both Cloth and Other than cloth

• Is there an area for donning and doffing of cloth face coverings?

  Yes

  No

• Are these cloth face coverings provided by the facility?

  Yes

  No

  N/A

• Who is responsible for laundering cloth face coverings?

  Select Employer only Employer, but employee can lauder their own if they want to. Employee only

  • Employer only
  • Employer, but employee can lauder their own if they want to.
  • Employee only

• Are laundered cloth face coverings provided at least daily?

  Yes

  No

• Are they being replaced when they are contaminated?

  Yes

  No

• Is there a mechanism for reporting supplies are low?

  Yes

  No

• Are there challenges in sourcing cloth face coverings?

  Yes

  No

• Are workers instructed about the need to launder cloth face coverings routinely?

  Yes

  No

• Are workers instructed about the need to launder cloth face coverings routinely?

  Yes

  No

• Do the face coverings interfere with PPE and performing of tasks?

  Yes

  No

• How has this been addressed?

• Are face coverings required for visitors/customers/clients?

  Yes

  No

• Completed by

  Sign