COVID-19 Safety Checklist Form

Please fill out the form with your information below.

Organization Name

    Location

      Date

        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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