*KT COVID 19 Job Site Hazard identification and Assessment

• Conducted on

  Date

• Prepared by

• Location
  Address

PERSONAL

• Have you or anyone in your residence traveled internationally within the past 14 days?

  Yes

  No

  N/A

• Have you monitored your health today?

  Yes

  No

  N/A

• Do you feel healthy?

  Yes

  No

  N/A

• Have you had a fever or known COVID symptoms such as: fever, compromised breathing, no taste/smell?

  Yes

  No

  N/A

• Have you been tested for COVID and waiting the results?

  Yes

  No

  N/A

• Have you been in close contact with anyone who has tested positive or is waiting the results of COVID testing? (within 6ft for 15 minutes)

  Yes

  No

  N/A

POTENTIAL EXPOSURE ON SITE / CREW

• Is anyone on site who is exhibiting symptoms of illness / COVID 19?

  Yes

  No

  N/A

• If yes, have they been removed from site?

  Yes

  No

  N/A

• Is anyone on site who has reported they have been tested for COVID and waiting results?

  Yes

  No

  N/A

• If yes, have they been removed from site?

  Yes

  No

  N/A

JOB SITE

• Do you have PPE on site needed to reduce exposure to COVID? (Porta Potty's / Handwashing Stations)

  Yes

  No

  N/A

• Are the COVID postings on site?

  Yes

  No

  N/A

• Are the trades using COVID PPE?

  Yes

  No

  N/A

• Are the trades able to social distance (6ft)?

  Yes

  No

  N/A

• Are the tradespeople on site able to follow the current CDC recommendations?

  Yes

  No

  N/A

• Are non-essential visitors refused entry?

  Yes

  No

  N/A

NOTES:

• Contractors on site?

• Job Sites you have traveled to today?

• Yes

  No

  N/A