Fillable COVID-19 AMBASSADOR ASSESSMENT (Michigan)

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COVID-19 AMBASSADOR ASSESSMENT (Michigan)

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This assessment is limited to the requirements of MIOSHA’s COVID-19 Emergency Rules.
Employers should continue to review Michigan.gov/COVIDWorkplaceSafety to ensure their
workplace COVID-19 policies and procedures are based on the most up-to-date information
available.
This form assesses the COVID-19 Preparedness and Response Plan at your facility. If an item
is not marked fully implemented, it represents an opportunity for improvement in workplace
protection.
COMPANY NAME DATE
ADDRESS PHONE NUMBER
CONTACT NAME PHONE NUMBER EMAIL
CONSULTANT NAME PHONE NUMBER EMAIL
3 2 1 N/A
Fully
Implemented
Partially
Implemented
Not
Implemented
Not
Applicable
COVID-19
AMBASSADOR ASSESSMENT
Status Key
Evaluate routine and reasonably anticipated tasks and
procedures to determine whether there is actual or reasonably
anticipated employee exposure to SARSCoV-2.
Categorize jobs tasks and procedures into the following risk
categories: Lower, Medium, High and Very high
Exposure Determination
Recommended Actions:
Recommended Actions:
GENERAL INDUSTRY REQUIREMENTS
Develop and implement a written COVID-19 preparedness and
response plan.
The plan shall include the employee exposure determination and
shall detail the measures the employer will implement to prevent
employee exposure, including any:
• Engineering controls
• Administrative controls
• Basic infection prevention measures
• Personal protective equipment
• Health surveillance and training
Make the preparedness and response plan readily available to
employees and their representatives.
COVID-19 Preparedness & Response Plan
Promote frequent and thorough hand washing, including by
providing workers, customers and worksite visitors with a
place to wash their hands. If soap and running water are not
immediately available, provide antiseptic hand sanitizers or
alcohol-based hand towelettes.
Require workers who are sick to not report to work or work in an
isolated location.
Prohibit workers from using other workers’ phones, desks,
oces or other work tools and equipment, when possible.
Increase facility cleaning and disinfection.
Establish procedures for disinfection if it is suspected or
confirmed that an employee, visitor, or customer has a known
case of COVID-19.
Use Environmental Protection Agency (EPA)-approved
disinfectants.
Follow the manufacturer’s instructions for use of all cleaning and
disinfection products.
Create a policy prohibiting in-person work for employees to
the extent that their work activities can feasibly be completed
remotely.
Basic Infection Prevention Measures
Recommended Actions:
Conduct a daily entry self-screening protocol for all employees
or contractors entering the workplace.
Direct employees to promptly report any signs and symptoms of
COVID-19 to the employer.
Physically isolate any employees known or suspected to have
COVID-19 from the remainder of the workforce.
When an employer learns of an employee, visitor or customer
with a known case of COVID-19 immediately notify the local
public health department and within 24 hours of learning of the
known case, notify any co-workers, contractors or suppliers who
may have come into contact with the person.
Allow employees with a known or suspected case of COVID-19 to
return to the workplace only after they are no longer infectious
and they are released from any quarantine or isolation order.
Health Surveillance
Recommended Actions:
Designate one or more worksite COVID-19 safety coordinators.
The COVID-19 safety coordinator must remain on-site at all times
when employees are present on site.
Place posters that encourage staying away from the workplace
when sick, cough and sneeze etiquette and proper hand hygiene
practices.
Workplace Controls
Keep everyone on the worksite premises at least 6 feet from
one another to the maximum extent possible and to reduce
congestion.
Provide non-medical grade face coverings to employees at no
cost to the employee.
Require face coverings to be worn when employees cannot
consistently maintain 6 feet of separation from other individuals
in the workplace.
Require face coverings in shared spaces.
Workplace Controls (cont’d)
Recommended Actions:
Provide employees with the types of personal protective
equipment, including respirators if necessary, for protection
from SARS-CoV-2 appropriate to the exposure risk associated
with the job.
Ensure that the personal protective equipment is properly fitted
and worn; used consistently; regularly inspected, maintained
and replaced, as necessary; and properly removed, cleaned and
stored or disposed of to avoid contamination of self, others or
the work environment.
Personal Protective Equipment
In establishments that provide medical treatment or housing
to known or suspected cases of COVID-19, the employer shall
ensure that employees in frequent or prolonged close contact
with such cases are provided with and wear, at a minimum, an
N95 respirator, goggles or face shield and a gown.
Personal Protective Equipment (cont’d)
Recommended Actions:
Recommended Actions:
Provide training to employees on SARS-CoV-2 and COVID-19.
Provide any communication and training on COVID-19 infection
control practices in the primary languages common in the
employee population.
Training shall cover:
• Workplace infection-control practices.
• The proper use of personal protective equipment.
• Steps the employee must take to notify the business or
operation of any symptoms of COVID-19 or a suspected or
confirmed diagnosis of COVID-19.
• How to report unsafe working conditions.
Provide updated training if changes are made to the
preparedness and response plan or new information becomes
available about the transmission of SARS-CoV-2 or diagnosis of
COVID-19.
Training
Maintain a record of the following
• Training
• Screening protocols
• Required notifications
Maintain records for one year from time of generation.
Recordkeeping
Recommended Actions:
Create communications material for customers (e.g., signs or
pamphlets) to inform them of changes to store practices and to
explain the precautions the store is taking to prevent infection.
Require patrons to wear a face covering (unless the patron is
unable medically to tolerate a face covering).
Post signs at store entrances instructing customers to wear a
face covering when inside the store.
Post signs at store entrances informing customers not to enter if
they are or have recently been sick.
Design spaces and store activities in a manner that encourages
employees and customers to maintain 6 feet of distance from
one another.
Install physical barriers at checkout or other service points that
require close interaction, including plexiglass barriers, tape
markers or tables.
Establish an enhanced cleaning and sanitizing protocol for
high-touch areas like restrooms, credit-card machines, keypads,
counters, shopping carts and other surfaces.
Retail, Libraries & Museums
INDUSTRY SPECIFIC REQUIREMENTS
Recommended Actions:
Require 6 feet of separation between parties or groups at
dierent tables or bar tops (e.g., spread tables out, use every
other table, remove or put up chairs or barstools that are not in
use).
Require patrons to wear a face covering except when seated at
their table or bar top (unless the patron is unable medically to
tolerate a face covering).
Prohibit access to common areas in which people can
congregate.
Create communications material for customers (e.g., signs,
pamphlets) to inform them of changes to restaurant or bar
practices and to explain the precautions that are being taken to
prevent infection.
Post signs at all entrances informing customers not to enter if
they are or have recently been sick.
Post signs instructing customers to wear face coverings until
they are seated at their table.
Require hosts, servers, and sta to wear face coverings in the
dining area in addition to areas where social distancing cannot
be maintained.
Restaurants & Bars
Recommended Actions:
Post signs at all entrances instructing customers to wear a face
covering when inside the facility.
Post signs outside of entrances instructing individuals not to
enter if they are or have recently been sick.
Mandate wearing of facial coverings at all times except when
swimming.
Provide equipment-cleaning products throughout the facility for
use on equipment.
Ensure that ventilation systems operate properly.
Sports & Exercise Facilities
Recommended Actions:
Websites
Michigan.gov/Coronavirus | Michigan.gov/MIOSHA | OSHA.gov | CDC.gov
Michigan.gov/COVIDWorkplaceSafety | Michigan.gov/MDHHS
Contact
MIOSHA Hotline
855-SAFE-C19 (855-723-3219)
Ask MIOSHA
MIOSHAinfo-gi@michigan.gov
Request for Consultation Assistance
517-284-7720 or visit Michigan.gov/CETRCA
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COVID-19 AMBASSADOR ASSESSMENT (Michigan)

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Completed 17 November 2020

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