Daily Level III Facility Inspection

• Conducted on

  Date

• Prepared by

• Location
  Address

• Policies post and clearly communicated to Employees, Customers and/or Vendors

  Yes

  No

• Illness reporting protocol in place and communicated to Employees at the location or scheduled to work.

  Yes

  No

• Communication protocol and channels are in place

  Yes

  No

• Sanitation protocols are up to date and communicated to each facility

  Yes

  No

• Hand sanitizing and human contact/distancing protocols communicated for all relevant scenarios at location.

  Yes

  No

• Adequate Social distancing signage and floor markings being used properly

  Yes

  No

• There is 14-day supply of Sanitizing solution/disinfectant per facility

  Yes

  No

• 14-day supply of single-use absorbent towels.

  Yes

  No

• On Hand, issued to employees by manager & (logged Daily including distribution quantity and recipient)

  Yes

  No

• Face Covering (preferably with the Enterprise Logo)

  Yes

  No

• Protective Gloves as needed

  Yes

  No

• Hand sanitizer

  Yes

  No

• Access to Soap, running water and single-use absorbent towels.

  Yes

  No

• Facility sanitation protocols are posted in employee areas, are up to date and accessible

  Yes

  No

• Sanitization responsibilities are scheduled and assigned to designated employees.

  Yes

  No

• Self-Certification document on file for each returning employee prior to arrival including digital temp.

  Select Compliant Missing E-I.D & Signature Missing Temperature record Missing Date & Time Missing Manager's Signature

  • Compliant
  • Missing E-I.D & Signature
  • Missing Temperature record
  • Missing Date & Time
  • Missing Manager's Signature

• Pre-shift Employee Temperature Log is Completed and Signed

  Select Compliant Missing E-I.D & Signature Missing Temperature record Missing Date & Time Missing Manager's Signature

  • Compliant
  • Missing E-I.D & Signature
  • Missing Temperature record
  • Missing Date & Time
  • Missing Manager's Signature

• COVID-19 symptoms and prevention information is posted, up to date, and accessible to all employees in multiple languages/reading level is appropriate for audience.

  Yes

  No

Customer Contact Spaces

• Self-sanitizing options, such as hand sanitizer and wipes, are available.

  Yes

  No

• Self-service areas have proper hygiene equipment like gloves in place or have been eliminated

  Yes

  No

• Proper Signage to direct customers upon arrival including in person protocols and expectations

  Yes

  No

• Adequate queuing area including clearly visible 6ft separation designators and anti-congregating flow.

  Yes

  No

Employee areas and Shared equipment are properly sanitized

• Phone Keypads and Handsets

  Yes

  No

• Counters and Workstations (Computer Screens, Keyboards and Mouse)

  Yes

  No

• Tablets and credit card readers

  Yes

  No

• Tablet and Handheld device charging stations

  Yes

  No

• General office equipment<br>• Printers<br>• Pens<br>

  Yes

  No

• Backrooms and separate office/workspaces

  Yes

  No

• Keys & Key Boxes / Safes

  Yes

  No

• Any paper logs or Clipboards

  Yes

  No

• Breakroom tables

  Yes

  No

• Chairs

  Yes

  No

• Refrigerators

  Yes

  No

• microwaves

  Yes

  No

• Alarm Panel

  Yes

  No

Public areas that are frequently touched are properly sanitized

•  Door & appliance handles

  Yes

  No

•  Display surfaces

  Yes

  No

•  Counters & Tables

  Yes

  No

•  Kiosk and any Self Check-out tools

  Yes

  No

•  Chairs including adjustment levers

  Yes

  No

•  Glass & Window covering adjustments

  Yes

  No

• Any Self-Service Vending machine equipment

  Yes

  No

• Door Handles

  Yes

  No

• sink faucets & toilet handles

  Yes

  No

• Towel Dispenser Handle or Activation knob

  Yes

  No

• Soap Dispenser Push Plate

  Yes

  No

• Baby Changing Station

  Yes

  No

• Trash receptacle touch points

  Yes

  No

• Cleaning Tools

  Yes

  No