Title Page
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Conducted on
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Prepared by
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Location
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Instructions to health department: You can use this questionnaire to help you prioritize worksite assessments. Information sources might include one or more employees at the company, such as human resources staff, occupational health staff, or a safety professional. Prior to using the questionnaire, determine priority categories for the final scores (e.g. low, medium, high) based on your current circumstances and resources.
Instructions to interviewer: If there are multiple worksites operated by the employer, it may be to complete the questionnaire separately for multiple worksites with confirmed or probable cases. If an employer reports no cases at the worksite, it is still recommended to ask all questions if other data sources indicate cases at the worksite are likely (e.g., worker complaints). -
1. Are you aware of any confirmed or probable COVID-19 cases at your worksite in the past 2 weeks?
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a. How many total cases have been confirmed in the past two weeks at your worksite?
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b. How many probable cases have you had in the past two weeks at your worksite?
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Scoring: Based on employer response or other information, does the number of confirmed positive plus probable cases (a+b) meet the minimum threshold for assessment as determined by your health department?
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c. How many total employees, contractors, and temp staff are at your worksite?
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d. Physical address
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Scoring: 1. Calculate the proportion of cases (a+b)/c at the worksite: 2. Obtain the most recent proportion of confirmed or probable cases for the local community of the worksite: Is the proportion of cases at the worksite greater than the proportion of cases in the local community?
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e. Did any employees diagnosed with COVID-19 come to the worksite within 48 hours before their symptoms began? Or, if the case didn’t show any symptoms, 48 hours prior to receiving a positive test result?
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f. Did any of the employees diagnosed with COVID-19 come to the worksite after symptoms began or after a positive test result?
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2. Is the worksite:
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• A school, daycare, youth program, or other provider of services to children?
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• A shared housing facility (e.g., adult living center)
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• A detention or correctional facility?
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Scoring: If yes to any of the above, This site is an automatic priority
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3. What is the primary function, or industry, of the worksite?
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Scoring: Is the worksite part of a critical infrastructure industry (as defined by the state/local jurisdiction)?
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4. Are employees able to maintain at least six feet of distance from other employees and customers/clients/visitors (if applicable) the majority of the time?
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Scoring: If no, check box:
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5. Do your employees have multiple in-person interactions with the public daily?
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Scoring: If yes, check box:
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6. Are you able to implement measures to prevent the spread of COVID-19, such as:
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a. Installing physical barriers between employee workstations or between employees and customers/clients/visitors?
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Scoring: If no, check box:
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b. Ensuring employees consistently and properly wear masks or cloth face coverings at the worksite?
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Scoring: If no, check box:
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c. Providing employees with soap and water for frequent handwashing and 60% alcohol-based hand sanitizer when there is no water available?
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Scoring: If no, check box:
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d. Ensuring worksite policies do not encourage sick workers to come to work, such as:
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i. Do you offer paid sick leave, either as a standing policy, or as a special contingency due to the COVID-19 pandemic?
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ii. Have you discontinued any bonus programs based on attendance?
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Scoring: If no to EITHER 6di OR 6dii, check box
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7. What estimated proportion of your workers speak a primary language other than English?
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Scoring: If 33% or more, check box:
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a. How many languages are spoken other than English?
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Scoring: If 3 or greater, check box:
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8. Is a substantial portion, such as one-third or more of your workforce, or the customers, clients, at higher risk for severe outcomes from COVID-19 due to age greater than 65 years, chronic health conditions such as chronic heart, lung, kidney or liver disease? Do they belong to groupsdisproportionately affected by COVID-19, such as some racial and ethnic minority groups, due to barriers to healthcare or socioeconomic status?
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Scoring: If yes, check box:
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9. Do your workers generally have access to housing where they could adequately isolate themselves if needed (i.e., with a separate bedroom and bathroom, enough space to stay 6 feet away from others when not in a separate area)? [Prompt: The concern is that workers with confirmed COVID-19, or exposed co-workers may have difficulty isolating or quarantining at home or are likely to expose high-risk family or household members.]
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Scoring: If no or unsure, check box:
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10. Are you considering arranging COVID-19 (SARS-CoV-2) testing for your employees at the worksite?
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Scoring: If yes, check box:
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Use your health department’s scoring guidance to determine the priority level of this worksite
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Total Number of Scored Checks (tally of checked boxes in scored rows) ; Total
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Completed by (Name and Signature)
