NZ COVID-19 Level 3 Work Daily Checklist - Personal

• Conducted on

  Date

• Prepared by

• Location
  Address

• Please remember, these are not normal times. However excessive these measures may seem, they allow our business to operate, and our economy to grow.
  
  They also save lives, and are the legal requirements for working at Alert Level 3. If there is another outbreak, the entire country will return to Alert Level 4, and many people, our business and the economy will continue to suffer.
  
  Please answer these questions as honestly and accurately as possible, regardless of how it may reflect on us as your employer. We are in a battle against an invisible enemy. Therefore, it is better to err on the side of caution as much as possible.

Your work conditions

• As far as you can see, are all work surfaces being disinfected at least once per day?

  Yes

  No

  N/A

• Are you washing your hands as much as is practicably possible?

  Yes

  No

  N/A

• Does your workplace have sufficient hand wash liquid or soap in the bathrooms?

  Yes

  No

  N/A

• Does your workplace have sufficient hand drying facilities in the bathrooms?

  Yes

  No

  N/A

• Does your workplace have sufficient hand sanitiser that is easily accessible for you outside the bathrooms?

  Yes

  No

  N/A

• Does the hand sanitiser to contain at least 60 percent alcohol content?

  Yes

  No

  N/A

• Are you ever working within 1 metre of a work colleague?

  No

  Yes

  N/A

• Are you having close interactions between groups of workers?

  No

  Yes

  N/A

• Are these group interactions necessary for work?

  Yes

  No

  N/A

• Please record the names of your work colleagues you are working closely with today?

  Select Employee 1 (John Smith) Employee 2 (Ian Brown) Employee 3 (Andy Johnson) Employee 4 (Sarah Green) Employee 5 (Anna Simpson) Employee 6 (Michelle Taylor) Other employee

  • Employee 1 (John Smith)
  • Employee 2 (Ian Brown)
  • Employee 3 (Andy Johnson)
  • Employee 4 (Sarah Green)
  • Employee 5 (Anna Simpson)
  • Employee 6 (Michelle Taylor)
  • Other employee

• Please list the names of the "Other" worker(s) who you are working with today?

• Have any customers been on your premises today?

  No

  Yes

  N/A

• Did you have any physical contact with these customers?

  No

  Yes

  N/A

• Did you go to a customer's site / residence for work today?

  No

  Yes

  N/A

• Did you get within 2 metres of the customer at any point in time?

  No

  Yes

  N/A

• Did / will you have to travel outside your city for work today?

  No

  Yes

  N/A

• Did / will you use public transport today to or from work today?

  No

  Yes

  N/A

• Did / will you likely sit or stand within 2 metres of another person on that public transport?

  No

  Yes

  N/A

Your personal health

• Do you have a cough?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Do you have a runny nose?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Are you sneezing a lot?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Do you feel like you have an unusually high temperature?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Do you have shortness of breath?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Do you have a sore throat?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Do you have a temporary loss of smell?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

The health of people you have interacted with

• Has anyone you live with shown any of these 7 symptoms listed above?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Has anyone you work with shown any of these 7 symptoms listed above?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• Has anyone you have been in contact with in the past 24 hours shown any of these 7 symptoms listed above?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

• As far as you know, has anyone you have been in contact with in the past two weeks tested positive for COVID-19?

  No

  Yes

  N/A

• Please follow immediate steps for testing your employees for COVID-19.

  

Sign Off

• I confirm that my answers above are 100% true and honest to the best of my knowledge. Please sign here with your full name and signature.

  Sign