Title Page
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Prepared by
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Date
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Location
Survey
- Survey
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Email address
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Do you plan to incorporate any of the below steps into your plan to resume operations/return to full-service levels? Select all that apply.
- Bringing employees back to the workplace in stages
- Staggering shifts
- Allowing continued work from home options
- Limiting face-to-face customer interactions
- Other
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Specify Other
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What requirements do you plan to put in place to provide a safe workplace for you, your employees and the Hoosiers they serve? Select all that apply.
- Health screenings
- COVID-19 testing
- Contact tracing to identify those who may have been exposed
- Self-isolation for those who may have been exposed
- Social distancing
- Use of personal protective equipment
- Other
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Specify Other
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Do you anticipate any service limitations as you plan to resume more normal operations? If yes, please explain.
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Please explain
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Name and Signature
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Title
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Company
