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Appendix A: Social Distancing Protocol (Updated April 29, 2020)
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 COVID-19 symptoms; 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; wear face coverings, as
appropriate; 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.
☐ Employees are required to wear face coverings, as appropriate.
☐ 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
☐ 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:
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 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.
Appendix A: Social Distancing Protocol (Updated April 29, 2020)
☐ Placing per-person limits on goods that are selling out quickly to reduce crowds and lines. Explain:
☐ Optional—Describe other measures:
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:
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):
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 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:
* Any additional measures not included here should be listed on separate pages and attached to this document.
You may contact the following person with any questions or comments about this protocol:
Name: Phone number:
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Completed 19 July 2020

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