Title Page
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Conducted on
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Prepared by
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Location
ENTRY TO/EXIT FROM BUILDING
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Schedule work shifts to reduce congregate settings and improve social distancing (i.e. stagger start and end times so all employees are not arriving and/or leaving at the same time)
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Install additional time clocks to prevent bottlenecks (if applicable)
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Hand sanitizer at entrances/exits
PERSONNEL SCREENING
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Pre-screen employees for fever and other symptoms prior to employees entering building
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Screen visitors to building
ENGINEERING CONTROLS
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Handwashing stations/hand sanitizers at every potential point of contact
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If fans are used in facility, blow clean air toward employees’ breathing zone
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Install high-efficiency air filters and increase ventilation rates in the work environment
EMPLOYEE TRAINING AND EDUCATION
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COVID safety training, presentation, or information shared (in all common languages used by workers)
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Posters/signs put up to encourage frequent and proper handwashing (in all common languages used by workers)
PERSONAL PROTECTIVE EQUIPMENT MEASURES
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Provide personal protective equipment (PPE) based on the hazard to worker (if applicable)
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PPE is properly fitted and periodically refitted, as applicable; regularly inspected, maintained, and replaced as necessary
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Train workers who use personal protective equipment how to properly put it on, use/wear, remove, clean and store to avoid contamination of self, others, and environment
ADMINISTRATIVE CONTROLS AND WORK PRACTICES
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All non-essential meetings, huddles, conferences cancelled
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Stagger breaks to minimize intermingling of team members and/or expand break areas
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All non-necessary visitors not admitted to building
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Enhanced cleaning of all common areas, including additional downtime for fogging with a sanitizer as needed
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Publicly posted sick leave policy
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Specific procedures for disinfecting
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Physical 6-foot markings on ALL work benches/tables/conveyors/assembly lines for distance markers
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Modify workstations to minimize close contact between workers; install physical barriers (e.g., plastic sneeze guards) or ensure 6 feet or more between employees
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Reduce production line staffing to extent feasible to minimize close worker contact
EMPLOYEE SAFETY AND HEALTH
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Process for identifying and separating employees who become ill/symptomatic while at work
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Flexible leave policies to accommodate workers who are ill and make employees aware of policies
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Sick workers able to stay home without fear of reprisals
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Do not require a healthcare provider’s note for employees who are sick with acute respiratory illness to validate their illness or return to work
SIGN OFF
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Completed by (Name and Signature)