Title Page

  • Company

  • Conducted on

  • Prepared by

  • Company Address

Control Site Traffic

  • Does facility have controlled means of entrance (single point, multiple entrances, etc..)

  • Once entered facility are there sign-in stations or check points restricting access to employee workstations or production areas

  • Are there controlled measures in place to minimize visitor/contractor access to facility when entering the property – escorted, PPE requirements, etc.…

  • Are the visitors/contractors allowed in the facility purposes mission critical

  • Are employees restricted when entering facility to a staging area.

  • Are temperatures or some form of wellness check being performed prior to working

  • Are visitors/contractors required to fill out wellness check or subject to a screening (temperatures, questionnaire, etc.…) prior to entering facility

  • Are commercial drivers refused entry to the facility and/or their access is limited to the shipping area and kept segregated from staff?

  • Are enhanced hygiene protocols for shipping/receiving areas such as personnel protective gear and enhanced cleaning conducted?

  • Are handwashing/sanitizing stations readily available in common areas?

  • Are all common areas sanitized by staff or outside cleaning agency on a regular basis?

  • Are common areas/breakroom seating reduced in accordance with current social distancing requirements?

  • Are current coronavirus exposure protocols being enforced? These include the following:<br>• Preventing immediate reentry to sites for all returning travelers from outside the normal employee basin<br>• If a test is ordered by a medical professional, are RI DOH guidelines followed with a minimum requirement to reenter of a confirmed virus free test result? https://health.ri.gov/covid/<br>• If test is positive, are the medical professional’s direction and RI DOH guidelines followed to include no reentry? https://health.ri.gov/covid/


  • Are promotional programs around hand washing and other best practices (“Do the 5”) being utilized?

  • Are enhanced cleaning of common touch points (doors, stairwell handle, light switch, time clock’s, surfaces) being conducted?

  • Have increased amounts of soap, hand sanitizer and cleaning materials been procured?

Social Distancing and Reduced Density

  • Are social distancing and reduced density requirements being implemented in accordance with Federal, State and local directives?

  • Have areas/schedules been altered to promote social distancing requirements (e.g. work areas, break rooms, work schedules, breaktimes, or blocations)?

  • If possible, are employees who can telework allowed to do so providing they maintain appropriate levels of safety and support?

  • Are breaks being staggered and seating in break rooms being reduced?

On-Site Emergency Response

  • Upon identification of a suspected coronavirus case, is the individual quarantined in a designated location until health officials can be contacted or the individual can safely return home or to a health facility?

  • Are all staff who come in contact with the individual asked to follow the latest RI DOH health guidelines for exposure?<br>https://health.ri.gov/covid/

  • Are all workspaces contacted by the individual deep cleaned? If so by whom?

Communication to Employees, Community and Customers

  • Are daily updates provided to all staff on the latest facts concerning the virus in our communities, how it impacts the business and their employment being provided?

  • Have chains of communication to enable rapid transmission of information to all staff without large meetings been developed?

  • Have the best practices from the CDC, WHO and RI DOH been promoted across the organization?<br>CDC: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html<br>WHO: https://www.who.int/<br>RI DOH: https://health.ri.gov/covid/

  • Has a crisis leadership team been formed to collect and respond to concerns from employees and the community?

Sign Off

  • Name and Signature

  • Title

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.