Details of Your Business
Name of Business
Owner/Manager of Business
Human Resources Representative and Contact Information, if applicable
Physical Distancing. To ensure employees comply with physical distancing requirements, you agree that you will do the following:
Ensure 6 ft. distance between personnel, unless safety or core function of the work activity requires
a shorter distance. Any time personnel are less than 6 ft. apart from one another, personnel must
wear acceptable face coverings
Tightly confined spaces will be occupied by only one individual at a time, unless all occupants are
wearing face coverings. If occupied by more than one person, will keep occupancy under 50% of
Post social distancing markers using tape or signs that denote 6 ft. of spacing in commonly used
and other applicable areas on the site (e.g. clock in/out stations, health screening stations)
Limit in-person gatherings as much as possible and use tele- or video-conferencing whenever
possible. Essential in-person gatherings (e.g. meetings) should be held in open, well-ventilated
spaces with appropriate social distancing among participants
Establish designated areas for pick-ups and deliveries, limiting contact to the extent possible.
List common situations that may not allow for 6 ft. of distance between individuals. What measures will you implement to ensure the safety of your employees in such situations?
How you will manage engagement with customers and visitors on these requirements (as applicable)?
How you will manage industry-specific physical social distancing (e.g., shift changes, lunch breaks) (as applicable)?
A. Protective Equipment. To ensure employees comply with protective equipment requirements, you
agree that you will do the following:
Employers must provide employees with an acceptable face covering at no-cost to the employee
and have an adequate supply of coverings in case of replacement.
What quantity of face coverings – and any other PPE – will you need to procure to ensure that you always have a sufficient supply on hand for employees and visitors? How will you procure these supplies?
Face coverings must be cleaned or replaced after use or when damaged or soiled, may not be
shared, and should be properly stored or discarded.
What policy will you implement to ensure that PPE is appropriately cleaned, stored, and/or discarded?
Limit the sharing of objects and discourage touching of shared surfaces; or, when in contact with
shared objects or frequently touched areas, wear gloves (trade-appropriate or medical); or, sanitize
or wash hands before and after contact.
List common objects that are likely to be shared between employees. What measures will you implement to ensure the safety of your employees when using these objects?
B. Hygiene and Cleaning. To ensure employees comply with hygiene and cleaning requirements, you
agree that you will do the following:
Adhere to hygiene and sanitation requirements from the Centers for Disease Control and Prevention
(CDC) and Department of Health (DOH) and maintain cleaning logs on site that document date, time,
and scope of cleaning
Who will be responsible for maintaining a cleaning log? Where will the log be kept?
Provide and maintain hand hygiene stations for personnel, including handwashing with soap, water,
and paper towels, or an alcohol-based hand sanitizer containing 60% or more alcohol for areas
where handwashing is not feasible.
Where on the work location will you provide employees with access to the appropriate hand hygiene and/or sanitizing products and how will you promote good hand hygiene?
Conduct regular cleaning and disinfection at least after every shift, daily, or more frequently as
needed, and frequent cleaning and disinfection of shared objects (e.g. tools, machinery) and
surfaces, as well as high transit areas, such as restrooms and common areas, must be completed.
What policies will you implement to ensure regular cleaning and disinfection of your worksite and any shared objects or materials, using products identified as effective against COVID-19?
C. Communication. To ensure the business and its employees comply with communication requirements, you agree that you will do the following:
Post signage throughout the site to remind personnel to adhere to proper hygiene, social distancing
rules, appropriate use of PPE, and cleaning and disinfecting protocols.
Establish a communication plan for employees, visitors, and customers with a consistent means to
provide updated information.
Maintain a continuous log of every person, including workers and visitors, who may have close
contact with other individuals at the work site or area; excluding deliveries that are performed with
appropriate PPE or through contactless means; excluding customers, who may be encouraged to
provide contact information to be logged but are not mandated to do so.
Which employee(s) will be in charge of maintaining a log of each person that enters the site (excluding customers and deliveries that are performed with appropriate PPE or through contactless means), and where will the log be kept?
If a worker tests positive for COVID-19, employer must immediately notify state and local health
departments and cooperate with contact tracing efforts, including notification of potential
contacts, such as workers or visitors who had close contact with the individual, while maintaining
confidentiality required by state and federal law and regulations.
If a worker tests positive for COVID-19, which employee(s) will be responsible for notifying state and local health departments?
A. Screening. To ensure the business and its employees comply with protective equipment requirements, you agree that you will do the following:
Implement mandatory health screening assessment (e.g. questionnaire, temperature check) before
employees begin work each day and for essential visitors, asking about (1) COVID-19 symptoms in
past 14 days, (2) positive COVID-19 test in past 14 days, and/or (3) close contact with confirmed or
suspected COVID-19 case in past 14 days. Assessment responses must be reviewed every day and
such review must be documented.
What type(s) of daily health and screening practices will you implement? Will the screening be done before employee gets to work or on site? Who will be responsible for performing them, and how will those individuals be trained?
If screening onsite, how much PPE will be required for the responsible parties carrying out the screening practices? How will you supply this PPE?
B. Contact tracing and disinfection of contaminated areas. To ensure the business and its employees comply with contact tracing and disinfection requirements, you agree that you will do the following:
Have a plan for cleaning, disinfection, and contact tracing in the event of a positive case.
In the case of an employee testing positive for COVID-19, how will you clean the applicable contaminated areas? What products identified as effective against COVID-19 will you need and how will you acquire them?
In the case of an employee testing positive for COVID-19, how will you trace close contacts in the workplace? How will you inform close contacts that they may have been exposed to COVID-19?
Please use this space to provide additional details about your business’s Safety Plan, including anything to address specific industry guidance.
Consult the NY Forward website at forward.ny.gov and applicable Executive Orders at
governor.ny.gov/executiveorders on a periodic basis or whenever notified of the availability of