COVID-19 Safety Checklist Form

Please fill out the form with your information below.

General Health and Safety Protocols

1. Employee Health Screening

• Daily temperature checks performed

• Employees with symptoms instructed to stay home

• Health declarations completed (if required)

2. Personal Protective Equipment (PPE)

• Face masks required for all employees and visitors

• Disposable gloves provided where necessary

• Face shields or other PPE available for high-contact roles

3. Social Distancing

• 6 feet distance maintained in common areas

• Workstations reconfigured to promote social distancing

• Signage posted to encourage physical distancing

4. Hand Hygiene and Sanitization

• Hand sanitizers placed at key entry points

• Handwashing stations available with soap and water

• High-touch surfaces disinfected frequently (e.g., doorknobs, light switches)

Workplace Environmental Measures

1. Ventilation

• HVAC system maintained and serviced regularly

• Windows and doors opened for increased airflow (where applicable)

2. Cleaning Procedures

• Regular deep cleaning of common areas

• Disinfecting wipes provided for personal workspace

3. Visitor and Customer Guidelines

• Visitors screened for symptoms upon entry

• Contactless payment options encouraged

• Signs posted with COVID-19 prevention guidelines

Acknowledgment and Compliance

I hereby confirm that the above checklist was completed accurately and all applicable safety measures are in place for today’s date.

Date:

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