Title Page

  • Conducted on

  • Facility Mailing Address
  • Division

  • Sub Division

  • Site Name

  • Alternative Site Name

  • Site Manager Name

  • Site EH&S Name

  • Submission Instructions:
    Interim Updates for the Scorecard (optional): Submit work in progress file (Excel or pdf) to appropriate contact or system.

    Final submission: Submit using the Certification Workflow Approval tool available on the Site Operations Checklist page, in the Certification block at the bottom. You will need these names:

  • Legend:
    Yes - Comments if needed:
    NO - Containment plan/Fix date:
    N/A - Why isn't it applicable?

1. Pandemic Response Management

  • A. Pandemic Response Team established, e.g., team identified, roles understood, operational

  • B. Corporate Protocols reviewed, adjusted to the particulars of the site, agreed upon with EH&S

  • C. Operational daily and shift change checklists created, responsibles identified and trained

2. Preventative Material Inventory

  • A. Adequate supply of cleaning supplies (e.g., soap, disinfectant, paper towels/tissues) or on order with sufficient lead time

  • B. 30-day supply of face masks on site or on order with sufficient lead time.

  • C. Adequate quantity and quality of non-touch thermometers on site for timely employee screening

3. Personal Protective Equipment

  • A. Review and understand the PPE protocol and guidance in the Playbook

4. Disinfection Measures

  • A. Site disinfected prior to anyone returning to work

  • B. Actions appropriate to ensure optimal turnover of fresh/clean air within the site (e.g. HVAC filters cleaned, return air fully open; bay and other doors opened where feasible)

  • C. General Disinfection Methods implemented per the protocols (e.g., cleaning approaches, frequency)

5. Deep Cleaning & Disinfection Protocol

  • A. Review, understand, and prepare for the triggering of the Deep-Cleaning and Disinfection Protocol

6. Inbound Parts/Materials/Packages

  • A. Incoming supply is managed according to Playbook standards

7. Layered Audit Checklist

  • A. eLPA audit process and software in-pace and trained, especially the pandemic-related audits

8. Transportation

  • A. Employee Transportation provider(s) have reviewed and implemented the Transportation Disinfection Checklist protocol

9. Isolation Protocol & Coordinator

  • A. Review and understand the Isolation protocol

  • B. Isolation Coordinator (volunteer) identified and trained

  • C. Protocol in place to isolate employees if she/he is symptomatic and on-site, including forms readily available

10. Social Distancing Protocol

  • A. Social Distancing Protocol reviewed, understood and implemented before start-up. Responsible assigned to check the site daily.

11. On-site Health Screening

  • A. Protocol established for pre-shift screening prior to site entry

  • B. Barriers are in place to prevent anyone from missing the screening

12. Daily Self-Screening Protocol

  • A. Daily Self-Screening protocol is distributed to all employees for voluntary, home self-screening

  • B. HR team prepared to receive inquiries or reports of symptomatic employees prior to shift

13. Self-Quarantining and Return to Work Protocol

  • A. Protocol reviewed, understood and adjusted as necessary for local, legal and cultural environment

14. Visitors & Contractors Self-Screening

  • A. Plan in place for screening Visitors and Contractors, including self-screening checklists printed and available?

15. Labor Relations Alignment

  • A. Local Unions educated on Pandemic Response Plan and Return to Work Protocols

16. Return to Work Training Plans

  • A. Day One training organized (e.g., attendee groups, logistics, schedules, trainers, feedback loop)?

17. Health & Wellness

  • A. Resources available to employees are understood and documented to be provided when requested

  • B. Employees will be surveyed regarding the safety procedures

18. Digital Communications and Signage

  • A. Adequate digital communication program in place to reach as many employees as possible, if needed

  • B. Physical signage posted

Overall Comments

  • Overall Comments

Certified for Accuracy

  • Site Manager (Sign)

  • PRT: Employee Access Control (Sign)

  • PRT: Virus Prevention (Sign)

  • PRT: Sanitization & Disinfection (Sign)

  • PRT: Communications & Training (Sign)

  • PRT: PPE (Sign)

Approved to Open

  • EH&S Director (Sign)

  • Operations VP (Sign)

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.