Fillable Appendix A- Social Distancing Protocol

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Appendix A- Social Distancing Protocol

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Social Distancing Protocol
COVID-19 Site-Specific Protection Plan
Business Name:
Facility Address: Click or tap here to enter text.
This Protocol was most recently updated on: Click or tap here to enter text.
Maximum number of people allowed in facility at any time:
Total Facility Square Footage:
Total Facility Square Footage Open to Public:
The Person Responsible for Implementing this Protocol
Name: Click or tap here to enter text. Title Click or tap here to enter text.
Phone number: Click or tap here to enter text. Email Address: Click or tap here to enter text.
Businesses must implement all applicable measures listed below and
be prepared to explain why any measure that is not implemented is inapplicable to the business.
Signage and Distribution:
☐ Post signage at each public entrance of the facility to inform personnel and customers of the following:
☐ Do not enter the facility if you have COVID-19 symptoms;
☐ Maintain a minimum six-foot distance from others, including when in line;
☐ Sneeze and cough into a cloth or tissue or, if not available, into your elbow;
☐ Face coverings required to enter (except if 6 years of age or under or medically inadvisable);
☐ Do not shake hands or engage in any unnecessary physical contact.
☐ Post signage at appropriate locations throughout the facility reminding customers to maintain social
distance.
☐ Post a copy of your COVID-19 PREPARED Sign and Social Distancing Protocol Visitor Information
Sheet at each public entrance to the facility where staff and customers can easily view them.
Personnel Training:
☐ Copies of this Protocol will be distributed to all personnel.
☐ Personnel are trained on COVID-19 information from the CDC, how to prevent COVID-19 from
spreading, who is especially vulnerable to the disease, and when to seek medical attention.
☐ Personnel are trained on screening themselves for COVID-19 symptoms, including temperature and/or
symptom checks using CDC guidelines.
☐ Personnel are trained on the need to stay home and get tested if they have a frequent cough, fever,
difficulty breathing, chills, muscle pain, headache, sore throat, recent loss of taste or smell, or if they or
someone they live with have been diagnosed with COVID-19.
Protocol Template Updated May 18, 2020 1
Social Distancing Protocol
COVID-19 Site-Specific Protection Plan
Personnel Training (continued)
☐ Personnel are trained on County guidelines for when it is safe to return to work if they are symptomatic
or have tested positive for COVID-19.
☐ Personnel are trained on the need for frequent handwashing with soap and water, proper use of face
coverings, the importance of social distancing, and other measures in this Protocol.
☐ Personnel are encouraged to get tested for COVID-19 in accordance with County guidance and given
information on test locations: https://www.sccgov.org/sites/covid19/Pages/covid19-testing.aspx.
☐ Personnel have been informed that they can contact the County Office of Labor Standards Enforcement
to report any deficiencies in compliance with Social Distancing Protocol requirements by this business:
Office of Labor Standards Enforcement Advice Line: 866-870-7725
☐ Personnel are trained on new or modified measures immediately upon updating this Protocol.
☐ Optional—Describe other measures:
Individual Control Measures and Screenings:
☐ All personnel who can carry out their work duties from home have been directed to do so and are doing
so.
☐ All workers have been directed not to come to work if sick or exhibiting symptoms of COVID-19.
☐ All employees are given temperature and other COVID-19 symptom screenings at the beginning of their
shift, and all other vendors, contractors, and other workers are screened before entering the facility.
☐ Require all persons to properly wear face coverings at all times in the facility (except if 6 years of age or
under, medically inadvisable, or the face covering would create a safety hazard for workers under
established health and safety guidelines).
☐ Optional—Describe other measures:
Handwashing and Hand-Sanitizing Protocols:
☐ Encourage frequent handwashing and use of hand sanitizer and provide frequent breaks for handwashing.
☐ Soap and water are available to all personnel at the following location(s): Click or tap here to enter text.
☐ Hand sanitizer effective against COVID-19 is available to all frontline staff as well as to other personnel at
the following location(s): Click or tap here to enter text.
☐ Hand sanitizer and/or soap and water are available to the public at or near the facility entrance, at checkout
counters, and at various locations throughout the facility to enable the public and staff to frequently clean their
hands.
Protocol Template Updated May 18, 2020 2
Social Distancing Protocol
COVID-19 Site-Specific Protection Plan
Handwashing and Hand-Sanitizing Protocols (continued)
☐ Ensure that handwashing and other sanitary facilities are operational and stocked at all times.
☐ Optional—Describe other measures:
☐ Thoroughly and regularly clean high traffic areas and frequently disinfect high-contact surfaces
(including doorknobs, handrails, counters, tables, checkout areas, cash registers, telephones, etc.).
☐ Break rooms, bathrooms, and other common areas are disinfected frequently, on the following schedule:
☐ Break rooms:
☐ Bathrooms:
☐ Other (Click or tap here to enter text.): Click or tap here to enter text.
☐ Disinfectant and related supplies are available to all employees at the following location(s):
Click or tap here to enter text.
☐ Disinfecting wipes that are effective against COVID-19 are available for use by customers and
personnel near shopping carts and baskets.
☐ Staff are assigned to disinfect carts and baskets regularly.
☐ Shared equipment and touchable surfaces like payment portals and pens are disinfected after each use.
☐ Adjust stores hours to provide adequate time for cleaning and stocking with social distancing, and
provide time for workers to clean between shifts.
☐ Optional—Describe other measures:
Click or tap here to enter text.
Measures to Maintain Social Distancing:
☐ To allow adequate social distancing (6 feet minimum) at all times and comply with any occupancy
limitations in the Order, limit the number of people in the facility at any one time to______ (see
applicable County guidance or directive for your facility type).
1. Total square footage of the facility:
2. Total square footage open to the public:
☐ Post an employee near the door to ensure that the maximum number of customers is not exceeded, that
all customers are wearing face coverings to enter (except children 6 years of age or under or persons for
whom face coverings are medically inadvisable), and that customers comply with other provisions of
this Protocol. Ensure that this employee is more than 6 feet away from customers to maintain adequate
social distance.
Protocol Template Updated May 18, 2020 3
Cleaning and Disinfecting Protocols
Social Distancing Protocol
COVID-19 Site-Specific Protection Plan
Measures to Maintain Social Distancing (continued)
☐ Place additional limitations on the number of workers in enclosed areas of the facilities (such as the
break rooms) to ensure at least six feet of separation.
☐ Place per-person limits on goods that are selling out quickly to reduce crowds and lines.
Explain: Click or tap here to enter text.
☐ Place tape or other markings at least six feet apart in customer line areas inside the store and on
sidewalks at public entrances with signs directing customers to use the markings to maintain distance.
☐ Separate order areas from delivery areas to prevent customers from gathering.
☐ Minimize exposure between cashiers and customers through social distancing or use of barriers where
social distancing cannot be maintained. Describe:
☐ Increase remote (online and telephone) purchasing, delivery, and curbside pickup service options.
☐ Instruct staff to maintain at least six feet of distance from customers and from each other, except staff
may momentarily come closer when necessary to accept payment, deliver goods or services, or perform
a job duty.
☐ Stagger personnel breaks, in compliance with wage and hour regulations, to maintain adequate social
distancing.
☐ Minimize any in-person meetings and adjust those that are necessary to ensure adequate social
distancing.
☐ All desks or individual workstations are separated by at least six feet.
☐ Reconfigure, restrict, or close break rooms and other common areas to maintain social distancing.
☐ Optional—Describe other measures:
Measures to Prevent Unnecessary Contact:
☐ Close all public seating areas.
☐ Prevent people from self-serving any food-related items, including from food bars, bulk-item bins, and
shared containers in breakrooms. Discontinue product sampling.
☐ Do not allow customers to use their own cups or other reusable food containers from home for
takeaway.
☐ Require customers using reusable bags from home to bag their own groceries or prevent use of reusable
bags from home. Describe:
Protocol Template Updated May 18, 2020 4
-------------------------------------- ------------------------------------------
Social Distancing Protocol
COVID-19 Site-Specific Protection Plan
Measures to Prevent Unnecessary Contact (continued)
☐ Provide contactless payment systems if possible.
☐ Optional—Describe other measures (e.g. providing senior-only hours):
Compliance Procedures:
☐ Regularly evaluate the workplace for compliance with this Protocol and document and correct
deficiencies.
☐ Personnel have been informed that they can call the County of Santa Office of Labor Standards
Enforcement at 1-866-870-7725 to report any deficiencies in compliance with Protocol requirements.
☐ Customers are informed that they can report any deficiencies in compliance with Protocol requirements
to County of Santa Clara Office of the District Attorney at www.santaclara-da.org
or pubhealthreferral@dao.sccgov.org.
Describe additional health and safety measures implemented for this facility:
Certification
I, Click or tap here to enter text. , affirm that all information in this Social Distancing Protocol is true and
accurate to the best of my knowledge, that all employees will be provided a copy of this Protocol and receive
trainings as required in this Protocol, that copies of the COVID-19 PREPARED Sign, Social Distancing
Protocol Visitor Information Sheet, and signage will be posted as required herein, and that all applicable
measures are being implemented as set forth herein.
Name Signature
Protocol Template Updated May 18, 2020 5
Social Distancing Protocol
Visitor Information
Last updated:
Learn More or Report a Complaint
To report a complaint about this or another business not following a Social Distancing
Protocol, visit www.santaclara-da.org or email pubhealthreferral@dao.sccgov.org.
To view the County Health Officer’s Order and other information related to COVID-19,
visit sccgov.org/coronavirus.
The person responsible for implementing this business’s protocol is:
Name
Title
Email
Phone Number
Business Name: ___________________________________________________________________
Facility Address:___________________________________________________________________
The maximum number of people allowed in this facility to ensure that people are easily
able to maintain six-foot social distancing, or as required by the Order, is ______________.
The total square footage of this facility is __________________.
The square footage of this facility open to the public is____________.
o Handwashing facilities or sanitizer is available near the facility entrance.
o An employee is posted at or near the facility entrance to ensure the maximum
number of customers is not exceeded and all persons are wearing face
coverings.
o
Tape or markings have been placed at least six feet apart where people form
sccgov.org/coronavirus
Santa Clara County Emergency Operations Center
Call: 2-1-1
Updated May 18, 2020
COVID-19 Prepared
This business has completed a Social Distancing Protocol to prevent the spread
of COVID-19.
For more information or to learn how to le a complaint, see this business’s
Social Distancing Protocol Visitor Information Sheet (required to be posted
with this sign) or visit sccgov.org/coronavirus.
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Appendix A- Social Distancing Protocol

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Completed 16 July 2020

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