Title Page

  • Conducted on

  • Prepared by

  • Location

ENTRY TO/EXIT FROM BUILDING

  • 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)

  • Install additional time clocks to prevent bottlenecks (if applicable)

  • Hand sanitizer at entrances/exits

PERSONNEL SCREENING

  • Pre-screen employees for fever and other symptoms prior to employees entering building

  • Screen visitors to building

ENGINEERING CONTROLS

  • Handwashing stations/hand sanitizers at every potential point of contact

  • If fans are used in facility, blow clean air toward employees’ breathing zone

  • Install high-efficiency air filters and increase ventilation rates in the work environment

EMPLOYEE TRAINING AND EDUCATION

  • COVID safety training, presentation, or information shared (in all common languages used by workers)

  • Posters/signs put up to encourage frequent and proper handwashing (in all common languages used by workers)

PERSONAL PROTECTIVE EQUIPMENT MEASURES

  • Provide personal protective equipment (PPE) based on the hazard to worker (if applicable)

  • PPE is properly fitted and periodically refitted, as applicable; regularly inspected, maintained, and replaced as necessary

  • 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

  • All non-essential meetings, huddles, conferences cancelled

  • Stagger breaks to minimize intermingling of team members and/or expand break areas

  • All non-necessary visitors not admitted to building

  • Enhanced cleaning of all common areas, including additional downtime for fogging with a sanitizer as needed

  • Publicly posted sick leave policy

  • Specific procedures for disinfecting

  • Physical 6-foot markings on ALL work benches/tables/conveyors/assembly lines for distance markers

  • Modify workstations to minimize close contact between workers; install physical barriers (e.g., plastic sneeze guards) or ensure 6 feet or more between employees

  • Reduce production line staffing to extent feasible to minimize close worker contact

EMPLOYEE SAFETY AND HEALTH

  • Process for identifying and separating employees who become ill/symptomatic while at work

  • Flexible leave policies to accommodate workers who are ill and make employees aware of policies

  • Sick workers able to stay home without fear of reprisals

  • 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

  • Completed by (Name and Signature)

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.