Fillable Appendix A: Social Distancing Protocol Facility Address: Click

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Appendix A: Social Distancing Protocol Facility Address: Click

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Appendix A: Social Distancing Protocol
Business name: Click or tap here to enter text.
Facility Address: Click or tap here to enter text.
Approximate gross square footage of space open to the public: 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:
☐Signage at each public entrance of the facility to inform all employees and customers that they
should: avoid entering the facility if they have a cough or fever; maintain a minimum six-foot
distance from one another; sneeze and cough into a cloth or tissue or, if not available, into one’s
elbow; and not shake hands or engage in any unnecessary physical contact.
☐Signage posting a copy of the Social Distancing Protocol at each public entrance to the facility.
Measures To Protect Employee Health (check all that apply to the facility):
☐ Everyone who can carry out their work duties from home has been directed to do so.
All employees have been told not to come to work if sick.
☐ Symptom checks are being conducted before employees may enter the work space.
☐ All desks or individual work stations are separated by at least six feet.
☐ Break rooms, bathrooms, and other common areas are being disinfected frequently, on the
following schedule:
☐ Break rooms:
☐ Bathrooms:
☐ Other (Click or tap here to enter text.: lick or tap here to enter text.
☐ Disinfectant and related supplies are available to all employees at the following location(s):
☐ Hand sanitizer effective against COVID-19 is available to all employees at the following location(s):
☐ Soap and water are available to all employees at the following location(s):
☐ Copies of this Protocol have been distributed to all employees.
☐ Optional—Describe other measures: Click or tap here to enter text.
Measures To Prevent Crowds From Gathering (check all that apply to the facility):
☐ Limit the number of customers in the store at any one time to (or other enter ),
which allows for customers and employees to easily maintain at least six-foot distance from one
another at all practicable times.
☐ Post an employee at the door to ensure that the maximum number of customers in the
facility set forth above is not exceeded.
☐ Placing per-person limits on goods that are selling out quickly to reduce crowds and lines.
Explain:
☐ Optional—Describe other measures: Click or tap here to enter text.
Electronic Fill Version Page 1 of 2
Select
Appendix A: Social Distancing Protocol
Measures To Keep People At Least Six Feet Apart (check all that apply to the facility)
☐ Placing signs outside the store reminding people to be at least six feet apart, including when in line.
☐
Placing 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.
☐ All employees have been instructed to maintain at least six feet distance from customers and from
each other, except employees may momentarily come closer when necessary to accept payment,
deliver goods or services, or as otherwise necessary.
☐ Optional—Describe other measures: Click or tap here to enter text.
Measures To Prevent Unnecessary Contact (check all that apply to the facility):
Preventing people from self-serving any items that are food-related.
☐ Lids for cups and food-bar type items are provided by staff; not to customers to grab.
☐ Bulk-item food bins
are not available for customer self-service use.
☐ Not permitting customers to bring their own bags, mugs, or other reusable items from home.
☐ Providing for contactless payment systems or, if not feasible, sanitizing payment systems regularly.
Describe:
☐ Optional—Describe other measures (e.g. providing senior-only hours):k or tap here to enter text.
Measures To Increase Sanitization (check all that apply to the facility):
☐ Disinfecting wipes that are effective against COVID-19 are available near shopping carts and
shopping baskets.
☐ Employee(s) assigned to disinfect carts and baskets regularly.
☐ Hand sanitizer, soap and water, or effective disinfectant is available to the public at or near the
entrance of the facility, at checkout counters, and anywhere else inside the store or immediately
outside where people have direct interactions.
☐ Disinfecting all payment portals, pens, and styluses after each use.
☐ Disinfecting all high-contact surfaces frequently.
☐ Optional—Describe other measures: Click or tap here to enter text.
*
Any additional measures not included here should be listed on separate pages, which the business should
attach to this document.
You may contact the following person with any questions or comments about this protocol:
Name: Click or tap here to enter text. Phone number: Click or tap here to enter text.
Electronic Fill Version Page 2 of 2
Social Distancing Protocol
Business Name: ______________________________________________________________________________________
Facility Address: _____________________________________________________________________________________
Approximate gross square footage of space open to the public: _______________________________________________
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:
Signage at each public entrance of the facility to inform all employees and customers that they should: avoid entering the
facility if they have a cough or fever; maintain a minimum six-foot distance from one another; sneeze and cough into a cloth
or ssue or, if not available, into one’s elbow; and not shake hands or engage in any unnecessary physical contact.
Signage posng a copy of the Social Distancing Protocol at each public entrance to the facility.
Measures To Protect Employee Health (check all that apply to the facility):
Everyone who can carry out their work dues from home has been directed to do so.
All employees have been told not to come to work if sick.
Symptom checks are being conducted before employees may enter the work space.
All desks or individual work staons are separated by at least six feet.
Break rooms, bathrooms, and other common areas are being disinfected frequently, on the following schedule:
Break rooms: ___________________________________________
Bathrooms: ____________________________________________
Other _________________________________________________
Disinfectant and related supplies are available to all employees at the following locaon(s): _________________________
Hand sanizer eecve against COVID-19 is available to all employees at the following locaon(s):_____________________
Soap and water are available to all employees at the following locaon(s): _______________________________________
Copies of this Protocol have been distributed to all employees.
Oponal—Describe other measures: ______________________________________________________________________
Measures To Prevent Crowds From Gathering (check all that apply to the facility):
Limit the number of customers in the store at any one me to ______________, which allows for customers and employees
to easily maintain at least six-foot distance from one another at all praccable mes.
Post an employee at the door to ensure that the maximum number of customers in the facility set forth above is not exceeded.
Placing per-person limits on goods that are selling out quickly to reduce crowds and lines. ___________________________
Oponal—Describe other measures: ___________________________________________________________________
Write-In Version Page 1 of 2
Placing signs outside the store reminding people to be at least six feet apart, including when in line.
Placing tape or other markings at least six feet apart in customer line areas inside the store and on sidewalks at public
entrances with signs direcng customers to use the markings to maintain distance.
Separate order areas from delivery areas to prevent customers from gathering.
All employees have been instructed to maintain at least six feet distance from customers and from each other, except
employees may momentarily come closer when necessary to accept payment, deliver goods or services, or as otherwise
necessary.
Oponal—Describe other measures: ______________________________________________________________
Measures To Prevent Unnecessary Contact (check all that apply to the facility):
Prevenng people from self-serving any items that are food-related.
Lids for cups and food-bar type items are provided by sta; not to customers to grab.
Bulk-item food bins are not available for customer self-service use.
Not perming customers to bring their own bags, mugs, or other reusable items from home.
Providing for contactless payment systems or, if not feasible, sanizing payment systems regularly. Describe: ___________
Oponal—Describe other measures (e.g. providing senior-only hours): ______________________________________
Measures To Increase Sanizaon (check all that apply to the facility):
Disinfecng wipes that are eecve against COVID-19 are available near shopping carts and shopping baskets.
Employee(s) assigned to disinfect carts and baskets regularly.
Hand sanizer, soap and water, or eecve disinfectant is available to the public at or near the entrance of the facility, at
checkout counters, and anywhere else inside the store or immediately outside where people have direct interacons.
Disinfecng all payment portals, pens, and styluses aer each use.
Disinfecng all high-contact surfaces frequently.
Oponal—Describe other measures: ___________________________________________________________
*Any addional measures not included here should be listed on separate pages, which the business should aach to this
document.
You may contact the following person with any quesons or comments about this protocol:
Name: ________________________________________ Phone number: ________________________________________
Measures To Keep People At Least Six Feet Apart (check all that apply to the facility)
Write-In Version Page 2 of 2
WE ARE PRACTICING
SOCIAL DISTANCING
Avoid entering the facility if you have a
cough or fever
Sneeze or cough into a cloth or tissue,
if not available, use your elbow
Do not shake hands or engage in any
unnecessary physical contact
We are implementing the mandatory social distancing protocols,
as per the Sacramento County Public Health Order until it is
extended, rescinded, superseded or amended by the Health Officer.
Max # of customers
allowed at one time:
Per person limitation on
High-Demand Goods:
Maintain a distance of 6 feet from others
WE ARE PRACTICING
SOCIAL DISTANCING
Avoid entering the facility if you have a
cough or fever
Sneeze or cough into a cloth or tissue,
if not available, use your elbow
Do not shake hands or engage in any
unnecessary physical contact
We are implementing the mandatory social distancing protocols, as
per the Sacramento County Public Health Order until it is extended,
rescinded, superseded or amended by the Health Officer.
Max # of customers
allowed at one time:
Per person limitation on
High-Demand Goods:
Maintain a distance of 6 feet from others
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Completed 4 August 2020

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