Fillable COVID-19 Healthcare Worksite Checklist & Employee Job Hazard (Department of Labor)

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COVID-19 Healthcare Worksite Checklist & Employee Job Hazard (Department of Labor)

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E M E R G E N C Y T E M P O R A R Y S T A N D A R D
COVID-19 Healthcare Worksite
Checklist & Employee Job Hazard Analysis
OSHA COVID-19 Healthcare Worksite Checklist
Employers in settings where employees provide healthcare services or healthcare support services may use
the following Worksite Checklist to implement worker protections from COVID-19 in compliance with the
OSHA COVID-19 Healthcare Emergency Temporary Standard (ETS).
If employers choose to use this Worksite Checklist, there are 2 STEPS to complete:
o STEP 1: Determine if OSHA’s COVID-19 Healthcare ETS applies to your workplace or portions of
your workplace.
o STEP 2: Use this Worksite Checklist to develop and implement worker protections from COVID-19 in
your workplace.
STEP 1: Determine if the ETS applies to your workplace or portions of your workplace.
You may use the “Is your workplace covered by the COVID-19 Healthcare ETS?” flow chart to determine whether and
how OSHA’s COVID-19 Healthcare ETS applies to your workplace. Note that this determination must be made for each
workplace where your employees work.
STEP 2: If the ETS applies to your workplace or portions of your workplace, use this
Worksite Checklist & Employee Job Hazard Analysis to develop and implement worker
protections from COVID-19 in your workplace.
Use the sections of this Worksite Checklist & Employee Job Hazard Analysis that apply to your workplace or portions
of your workplace to develop and implement worker protections from COVID-19. This checklist is intended to be used
alongside OSHA’s COVID-19 Plan Template to help you develop and implement a COVID-19 plan, as required by the
ETS, for your workplace. Seek the involvement of non-managerial employees and their representatives in completing
this checklist and implementing the COVID-19 plan.
Getting Started
Take these steps to get your workplace ready and ensure you have
implemented policies and procedures to prevent the spread of
COVID-19. Some specific controls against COVID-19 and a job hazard
analysis are covered in the sections that follow.
YES
NO
Follow-up Action
o Do you have a COVID-19 plan that was developed in consultation with non-
managerial employees?
o If you are claiming exemption under 1910.502(a)(4) from providing controls for
fully vaccinated employees in a well-defined area(s) of the workplace where
there is no reasonable expectation that any person with suspected or confirmed
COVID-19 will be present, do you have policies and procedures in place to
determine employees’ vaccination status?
o Have you shared your COVID-19 plan with all other employers at your
worksite(s) and coordinated to ensure all workers are protected?
o Do you have policies to limit and monitor points of entry in settings where direct
patient care is provided?
(Note: Does not apply where emergency responders or other licensed healthcare
providers enter a non-healthcare setting to provide healthcare services.)
o Do you have a policy to screen and triage all clients, patients, residents, delivery
people, visitors, and other non-employees entering settings where direct patient
care is provided for people who may have symptoms of COVID-19?
Reset Form
Take these steps to get your workplace ready and ensure you have
implemented policies and procedures to prevent the spread of
COVID-19. Some specific controls against COVID-19 and a job hazard
analysis are covered in the sections that follow.
YES
NO
Follow-up Action
o Do you have a health screening protocol for screening employees before each
work day and each shift?
o Do you have a log for recording all employee instances of COVID-19?
o Do you have a policy that requires employees to notify you when they are
COVID-19 positive or have been told by a licensed healthcare provider that they
are suspected of having COVID-19?
o Does the policy require employees to notify you if they are experiencing
COVID-19 like symptoms including:
A recent loss of taste and/or smell with no other explanation
A fever of at least 100.4°F with a new unexplained cough associated with
shortness of breath
o Do you have a policy to notify employees within 24 hours, if required to do so,
when they have been exposed (through close contact or by working in the same
well-defined portion of a workplace during a person’s potential transmission
period) to a COVID-19 positive person who has been in the workplace?
o Do you have a policy for employee COVID-19 testing, including providing time
off and payment for the test? (Note: employers are not required to conduct
testing)
o Do you have policies to remove employees who have COVID-19, are suspected
to have COVID-19, are experiencing certain symptoms of COVID-19, or have
been in close contact with a COVID-19 positive person in the workplace, until
they can return as provided for by the standard, and, for employers with more
than 10 employees, to provide medical removal protection benefits to such
employees where required to do so (see OSHA’s ETS Notification, Removal,
and Return to Work Flow Chart for Employers and Employees)?
o Do you have policies and procedures for adhering to Standard and Transmission-
Based Precautions in accordance with CDC’s “Guidelines for Isolation
Precautions”?
o Have you considered the use of telehealth services where available and
appropriate in order to limit the number of people entering the facility? (Note:
employers are not required to, but are encouraged to, use telehealth where
available and appropriate.)
o Do you have a plan to support COVID-19 vaccination by providing each
employee reasonable time and paid leave for vaccination and any side effects
experienced following vaccination?
(Note: Eligible employers, including businesses and tax-exempt
organizations with fewer than 500 employees, can receive a tax credit for
providing paid time off for each employee receiving the vaccine and for any
time needed to recover from the vaccine. See
www.irs.gov/newsroom/american-rescue-plan-tax-credits-available-to-
small-employers-to-provide-paid-leave-to-employees-receiving-covid-19-
vaccines-new-fact-sheet-outlines-details)
Identify COVID-19 Safety Coordinators to ensure compliance with all aspects of the COVID-19 plan.
Name:
Position/Title/Campus:
Physical Distancing in your Workplace
This section will assist you in implementing physical distancing measures at your workplace.
o Employers must ensure that employees are separated from other people by at least 6 feet when indoors, and install cleanable or
disposable solid barriers at fixed work locations outside of direct patient care areas where each employee is not separated from
other people by at least 6 feet, unless the employer can demonstrate that these measures are infeasible. Refer to the Fixed Work
Location and Job Task Inventory for Employees Outside of Direct Patient Care Areas Who Cannot Maintain Physical
Distancing and the Job Hazard Analysis (Controls) sections below.
o In evaluating how to implement physical distancing, employers should consider these measures as they build their
COVID-19 plans.
o Employers must implement physical distancing along with the other provisions required by the ETS as part of a multi-layered
strategy to minimize employee exposure to COVID-19.
o NOTE: The ETS exempts fully vaccinated workers from physical distancing and barrier requirements when in well-defined
areas where there is no reasonable expectation that any person with suspected or confirmed COVID-19 will be present.
Have you considered these measures when/where possible?
YES
NO
Follow-up Action
o Have you taken steps to reduce crowding in facilities by asking patients to remain
outside if feasible until they are called into the facility for their appointment?
For example: Vehicle waiting area in parking lot, open air triage tents and
booths, etc.
o Have you limited visitors to the facility to only those essential for the patient’s
physical or emotional well-being and care, and restricted their visits to the
patient’s room or other designated areas?
o Have you implemented teleworking options?
o Are physical distancing floor markers and/or visible wall signs in place to remind
employees, patients, visitors, customers, clients, and all other non-employees to
maintain a minimum distance of 6 feet between them?
o Have you reconfigured the work environment to ensure physical distancing?
For example: Spacing out desks, etc.
o Have conference rooms and break area furnishings (tables, chairs, desks) been
adjusted to maintain physical distancing?
o Have you installed cleanable or disposable solid barriers at each fixed work
location outside of direct patient care areas (e.g., entryway/lobby, check-in desks,
triage, hospital pharmacy windows, bill payment) where each employee is not
separated from all other people by at least 6 feet of distance?
o Have work shifts and break times been staggered to reduce crowding in common
employee areas?
For example: Breakrooms, locker rooms, etc.
o Have you taken steps to minimize the number of people within choke points
(bottlenecks) at any time to ensure a minimum distance of 6 feet can be
maintained between them and reduce crowding?
For example: Outside of direct patient care areas (e.g., entryway/lobby, check-in
desks, triage, pharmacy windows, bill payment).
o Have you designated pickup/drop-off delivery areas away from high traffic areas?
o Have you used scheduling to separate workers into dedicated groups (i.e.
“bubbles” or “cohorts”) to work the same shift or work in a particular area to
reduce the number of individuals that each worker encounters?
o Have contactless payment systems been established?
o Have contactless scheduling systems been established?
Ventilation in Your Workplace
This section will assist you in improving ventilation at your workplace.
o Employers who own or control buildings or structures with an existing heating, ventilation, and air conditioning (HVAC)
system(s) must ensure that the HVAC system(s) is used in accordance with manufacturer's instructions and the design
specifications of the system(s); the amount of outside air circulated through the system(s) and the number of air changes per
hour are maximized to the extent appropriate; air filters are rated Minimum Efficiency Reporting Value (MERV) 13 or higher, if
compatible with the HVAC system(s); air filters are maintained and replaced as necessary; intake ports are cleaned, maintained,
and cleared of debris; and airborne infection isolation rooms (AIIRs) are maintained and operated in accordance with their
design and construction criteria.
o Does your workplace have a HVAC system that you own or control?
o Who is responsible for maintaining the HVAC system(s) and can certify that it is operating in accordance with the
ventilation provisions of the OSHA COVID-19 ETS?
(e.g., Maintenance staff, HVAC service contractor)
Name/Contact Information:
Have you taken these measures where/when possible?
YES
NO
Follow-up Action
o Is the HVAC system being checked, inspected, cleaned, and maintained on a
regularly scheduled basis?
o Is the HVAC system being used in accordance with the HVAC
manufacturer’s instructions and design specifications?
o Is the HVAC system set to maximize the amount of fresh outdoor air that is
supplied to the system within the system’s capabilities?
o Are the HVAC outdoor air intakes clean, are they in good working order, and
are they clear of obstructions?
o Are the HVAC air filters that are installed rated at least Minimum Efficiency
Reporting Value (MERV) 13, or the highest level compatible with the
system?
o Are all air filters maintained and changed as necessary in accordance with the
manufacturer’s instructions for proper HVAC system function?
o Are all air supply diffusers and return air grilles open, clean, and operating
properly?
o Are all existing AIIRs maintained in accordance with design and construction
criteria?
Additional Ventilation Strategies (Best Practices) to Consider
YES
NO
Notes
o Are windows and doors opened when ambient air quality and temperature
allow, and if doing so would not pose other health or safety risks?
o Are automatic settings that reduce outside air intake disabled?
o Are HVAC system(s) operated at least two hours before people arrive and at
least two hours after everyone has left in order to help flush the building?
Cleaning and Disinfection in Your Workplace
This section will assist you in implementing cleaning, disinfection, and hand hygiene measures at your workplace.
o In patient care areas, resident rooms, and for medical devices and equipment, employers must follow standard practices for
cleaning and disinfection of surfaces and equipment in accordance with CDC’s “COVID-19 Infection Prevention and Control
Recommendations” and CDC’s “Guidelines for Environmental Infection Control,” pp. 86–103, 147-149. In all other areas,
employers must clean high-touch surfaces and equipment at least once a day, following manufacturers’ instructions for
application of cleaners; and clean and disinfect, in accordance with CDC’s “Cleaning and Disinfecting Guidance” any areas,
materials, and equipment under the employer’s control that have likely been contaminated by a person who is COVID-19
positive and has been in the workplace within the last 24 hours.
o Employers must provide alcohol-based hand rub that is at least 60% alcohol or provide readily accessible hand washing facilities.
o After aerosol-generating procedures (AGPs) are performed on persons with suspected or confirmed COVID-19, employers
must clean and disinfect the surfaces and equipment in the room or area where the procedure was performed.
Have you taken these measures where/when possible?
YES
NO
Follow-up Action
o Are patient care areas, resident rooms, and medical devices and equipment
cleaned and disinfected in accordance with the CDC’s “COVID-19 Infection
Prevention and Control Recommendations” and “Guidelines for Environmental
Infection Control”?
o Do you clean and disinfect areas, materials, and equipment (other than patient
care areas, resident rooms, and medical devices and equipment) that have likely
been contaminated by a person with COVID-19 who has been in the workplace
within the last 24 hours in accordance with the CDC’s “Cleaning and
Disinfecting Guidance”?
o Where AGPs are conducted, do you clean and disinfect the surfaces and
equipment in the room or area after the procedure is completed?
o Have you provided alcohol-based hand rub that is at least 60% alcohol or
provided readily accessible handwashing facilities for employees, patients,
visitors, customers, clients, and all other non-employees?
o Outside of patient care areas and patient rooms, are high-touch surfaces and
equipment (other than medical devices and equipment) cleaned at least once a
day following manufacturers’ instructions for application of cleaners?
o When disinfecting, do you use a disinfectant found on EPA’s List N;
Disinfectants for COVID-19?
Personal Protective Equipment (PPE) in Your Workplace
This section will assist you in providing PPE and implementing PPE policies at your workplace.
o Employers must: provide and ensure employees wear facemasks that are FDA-cleared, authorized by an FDA EUA, or
otherwise offered or distributed as described in an FDA enforcement policy; ensure a facemask is worn by each employee over
the nose and mouth when indoors and when occupying a vehicle with other people for work purposes (with some exceptions,
e.g., when an employee is alone in a room); provide and ensure employees use respirators and other PPE for exposure to people
with suspected or confirmed COVID-19 and for AGPs performed on a person with suspected or confirmed COVID-19; provide
respirators and other PPE in accordance with Standard and Transmission-based Precautions in healthcare settings in accordance
with CDC’s “Guidelines for Isolation Precautions”; and allow employees to wear their own respirators instead of facemasks
(under the mini respiratory protection program at 29 CFR 1910.504).
o NOTE: PPE requirements for employees with exposure to a person with suspected or confirmed COVID-19 and for AGPs on a
person with suspected or confirmed COVID-19 are discussed in the Job Task Inventory for Employees with Potential for
Exposure to a Person with Confirmed or Suspected COVID-19 and Job Hazard Analysis (Controls) sections below.
o NOTE: The ETS exempts fully vaccinated workers from PPE requirements when in well-defined areas where there is no
reasonable expectation that any person with suspected or confirmed COVID-19 will be present.
The following questions apply when employees are required to wear employer-
provided facemasks, respirators, or face shields:
YES
NO
Follow-up Action
o Do you ensure facemasks are worn by employees over the nose and mouth when
indoors and when occupying a vehicle with other people for work, unless one of
the exceptions in the ETS applies?
o When facemasks are required, have you provided to each employee a sufficient
number of facemasks that are FDA-cleared, authorized by an FDA EUA, or
otherwise offered or distributed as described in an FDA enforcement policy to
comply with the ETS and ensure that they are changed by employees at least once
a day, whenever they are soiled or damaged, and more frequently as necessary?
o If N95 respirators or a higher level of respiratory protection are provided to
employees, are they:
o used in accordance with the COVID-19 mini respiratory protection program
(29 CFR 1910.504) when used in place of a facemask in situations when a
respirator is not required by the ETS; or
o used in accordance with the respiratory protection standard (29 CFR 1910.134)
when a respirator is required by the ETS?
o For employees who are unable to wear facemasks (e.g., due to a disability), are
face shields provided to employees and
o certified to ANSI/ISEA Z87.1 (or do they cover the wearer’s eyes, nose, and
mouth, wrap around the face from temple to temple, and extend down below
the wearer’s chin)?
o cleaned at least daily?
o replaced when damaged?
o Instead of a facemask, are employees permitted to wear their own respirator used in
accordance with 29 CFR 1910.504 when a respirator is not required by the ETS?
Fixed Work Location and Job Task Inventory for Employees Outside of
Direct Patient Care Areas Who Cannot Maintain Physical Distancing
Use this Fixed Work Location and Job Task Inventory and input from employees to identify any fixed work
locations outside of direct patient care areas where employees cannot maintain at least 6 feet of physical
distancing from all other people when indoors. Direct patient care means hands-on, face-to-face contact with
patients for the purpose of diagnosis, treatment, and monitoring.
Note: The ETS exempts fully vaccinated workers from physical distancing and barrier requirements when in
well-defined areas of the workplace where there is no reasonable expectation that any person with suspected or
confirmed COVID-19 will be present.
Fixed work locations are workstations where an employee is assigned to work for significant periods of time. Protective measures
can often be implemented at fixed workstations to minimize potential exposure to COVID-19.
o Take an inventory of all fixed work locations outside of direct patient care areas where employees cannot maintain 6 feet of
physical distance from all other people. Note the number of workers at each location.
For example: 5 administrative employees work at an outpatient medical office with fixed work locations at:
The reception area
Employee desk area not in direct patient care areas
o For each fixed work location, describe the job tasks where employees cannot maintain 6 feet of physical distance from all
other people.
For example: For the outpatient medical office:
2 employees in the reception area interact with patients, families, and the public to conduct administrative
tasks at the reception desk
3 employees work at their desks not in direct patient care areas
Fixed Work
Location
No. of
Workers
Job Tasks and Descriptions
For example:
Outpatient
medical office
The
reception
area
2
Interact with patients, families, and the public to conduct administrative tasks at the
reception desk
Employee
desk area
3
Work at their desks not in direct patient care areas
Job Task Inventory for Employees with Potential for Exposure to a Person
with Suspected or Confirmed COVID-19
Use this Job Task Inventory and input from employees to identify any job tasks where employees have
potential for exposure to a person with suspected or confirmed COVID-19.
Answer the following questions about employee exposure to COVID-19:
YES
NO
Follow-up / Notes
Do employee(s) provide direct care to or are they otherwise exposed to people with
suspected or confirmed COVID-19?
Do employee(s) perform or assist in performing AGPs on a person with suspected or
confirmed COVID-19? The following medical procedures are considered AGPs:
open suctioning of airways
sputum induction
cardiopulmonary resuscitation
endotracheal intubation and extubation
non-invasive ventilation (e.g., BiPAP, CPAP)
bronchoscopy
manual ventilation
medical/surgical/postmortem procedures using oscillating bone saws
dental procedures involving: ultrasonic scalers; high-speed dental handpieces;
air/water syringes; air polishing; and air abrasion
If you answered yes to any of the questions above, complete the table below indicating the location(s), number of workers, and
job tasks and descriptions in which employees have potential for exposure to a person with suspected or confirmed COVID-19.
Location(s)
No. of
Workers
Job Tasks and Descriptions
For example:
Surgical Suites
5
Perform or assist in surgical procedures using oscillating bone saws
Are there any well-defined areas of your workplace in which there is no reasonable expectation that any person with
suspected or confirmed COVID-19 will be present? If yes, list here:
For example: employee break room
Employee Job Hazard Analysis (Controls)
This form will help employers and their employees identify controls to implement to minimize potential employee exposure
to COVID-19. Refer to the Fixed Work Location and Job Task Inventory for Employees Outside of Direct Patient Care
Areas Who Cannot Maintain Physical Distancing as well as the Job Task Inventory for Employees with Potential for
Exposure to a Person with Suspected or Confirmed COVID-19 sections above to complete this form for every fixed work
location or job task identified in these sections.
At least one non-managerial employee should provide input on this Job Hazard Analysis.
Employee Name(s), Position/Title, Shift
Facility Location (e.g., campus, building number)
Controls to implement (as appropriate and feasible) for employees outside of direct patient care areas
who cannot maintain physical distancing
Fixed Work Location(s) (refer to table above):
Job Tasks and Descriptions:
☐ Work processes or procedures have been adjusted to ensure that employees are as far apart as feasible from other people.
How:
for example: using a lifting device instead of a co-worker
Physical barriers have been installed where physical distancing is not feasible.
NOTE: Physical barriers are not required in direct patient care areas or resident rooms. The ETS also exempts fully vaccinated workers
from physical distancing and barrier requirements when in well-defined areas of the workplace where there is no reasonable expectation
that any person with suspected or confirmed COVID-19 will be present. Refer to list of well-defined areas above.
Between employees and other people where possible
Between co-worker workstations where possible
Barriers are at height and width to block face-to-face pathways between persons
Small pass-through openings for objects, if necessary, are located at the bottom of the barrier and away from users’
breathing zones
Barriers are fixed or secured so they do not move excessively (secured to ground or surface; hanging barriers have bottoms
secured)
Barriers are easily cleanable or disposable
o Barrier cleaning supplies are stocked and conveniently located
Barriers do not block emergency exits and pathways
Controls to implement for employees with potential for exposure to a person with suspected or
confirmed COVID-19
Controls for AGPs performed on a person with suspected or confirmed COVID-19:
The number of employees present during the procedure is limited to only those essential for patient care and procedure support
The procedure is performed in an AIIR, if available
All surfaces and equipment in the room or area where the procedure is performed are cleaned and disinfected after the procedure
is completed
PPE:
The employer must provide a respirator, gloves, an isolation gown or protective clothing, and eye protection to each employee with
exposure to people with suspected or confirmed COVID-19. The employer must ensure that the respirator is used in accordance
with the respiratory protection standard (29 CFR 1910.134) and that other PPE is used in accordance with 29 CFR 1910 subpart I.
For AGPs performed on a person with suspected or confirmed COVID-19, employers are encouraged to select elastomeric
respirators or PAPRs instead of filtering facepiece respirators.
Use this form for each healthcare job task (refer to table above) with potential exposure to COVID-19.
Description of Job Task
Employee Protections
Provided by
Employer
Follow-up / Notes
For example: A nurse in the ICU must
enter the patient’s room and draw
three vials of blood once daily in the
morning before breakfast.
The patient is positive for COVID-19.
The ICU nurses have been issued N95
respirators. ICU nurses wear FDA-
authorized facemasks when not in a
COVID-19 positive patient’s room.
Gloves
x
Isolation gown
x
Facemasks cleared by the FDA, authorized by
an FDA EUA, or offered or distributed as
described in an FDA enforcement policy
x
When not wearing N95 respirator
N95 respirator, or equivalent
x
Goggles or face shield
x
Powered air-purifying respirator (PAPR)
Airborne infection isolation room (AIIR)
Other, specify:
Gloves
Isolation gown
Facemasks cleared by the FDA, authorized by
an FDA EUA, or offered or distributed as
described in an FDA enforcement policy
N95 respirator, or equivalent
Goggles or face shield
Powered air-purifying respirator (PAPR)
Airborne infection isolation room (AIIR)
Other, specify:
Gloves
Isolation gown
Facemasks cleared by the FDA, authorized by
an FDA EUA, or offered or distributed as
described in an FDA enforcement policy
N95 respirator, or equivalent
Goggles or face shield
Powered air-purifying respirator (PAPR)
Airborne infection isolation room (AIIR)
Other, specify:
Controls to implement for contact with other people while occupying a vehicle for work
Identify the protective measures taken when employees occupy a vehicle with another person for work purposes.
Required by the ETS:
Facemasks are worn over the nose and mouth
Clean high-touch surfaces daily (e.g., steering wheel, door handles, seats)
Best practices for employee protection:
Use fan at highest setting
DO NOT use “Recirculate” for cabin heating/cooling
Open window(s) whenever weather permits
Separate workers as much as possible in the vehicle (e.g., avoid having persons sit side-by-side)
Action Items from Job
Hazard Analysis:
Follow up to Action Items:
Implementing a COVID-19 Training Program
Ensure that all employees receive training, in a language and at a literacy level that they can understand.
Have you trained each employee on COVID-19 health hazards including
providing information about:
YES
NO
Follow-up Action
How COVID-19 is transmitted (including pre-symptomatic and asymptomatic
transmission)
The importance of hand hygiene to reduce the risk of spreading COVID-19
infections
Ways to reduce the risk of spreading COVID-19 through the proper covering of
the nose and mouth
The signs and symptoms of COVID-19
The risk factors for severe illness
When to seek medical attention
Have you reviewed your COVID-19 plan, policies, and procedures with your
employees, including:
Where to find the plan, and how to obtain copies
Name(s) and Contact(s) of the COVID-19 Safety Coordinator(s)
The completed Workplace Checklist, Fixed Work Location and Job Task
Inventory for Employees Outside of Direct Patient Care Areas Who Cannot
Maintain Physical Distancing, Job Task Inventory for Employees with Potential
for Exposure to a Person with Suspected or Confirmed COVID-19, and the
Employee Job Hazard Analysis (Controls), and how to obtain copies of each
Your specific policies and procedures on patient screening and management
Tasks and situations in the workplace that could result in COVID-19 infection
Your specific policies and procedures to prevent the spread of COVID-19 that are
applicable to the employee’s duties (e.g., policies on Standard and Transmission-
Based Precautions, physical distancing, physical barriers, ventilation, aerosol-
generating procedures)
Your specific multi-employer workplace agreements related to infection control
policies and procedures, the use of common areas, and the use of shared
equipment that affect employees at the workplace
Your specific policies and procedures for PPE for your workplace including:
o When PPE is required for protection against COVID-19
o Limitations of PPE for protection against COVID-19
o How to properly put on, wear, and take off PPE
o How to properly care for, store, clean, maintain, and dispose of PPE
o Any modifications to donning, doffing, cleaning, storage, maintenance, and
disposal procedures needed to address COVID-19 when PPE is worn to
address workplace hazards other than COVID-19
Your specific policies and procedures for cleaning and disinfection
Your specific policies and procedures on health screening and medical management
Available sick leave policies, any COVID-19-related benefits to which the
employee may be entitled under applicable federal, state, or local laws; and other
supportive policies and practices (e.g., telework, flexible hours)
Training Requirements / Notes:
Employee Representative Name and Date:
COVID-19 Safety Coordinator Name and Date:
This document is intended to provide information about the COVID-19 Emergency Temporary Standard. The Occupational Safety and Health Act requires employers to comply with safety and
health standards promulgated by OSHA or by a state with an OSHA-approved state plan. However, this document is not itself a standard or regulation, and it creates no new legal obligations.
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COVID-19 Healthcare Worksite Checklist & Employee Job Hazard (Department of Labor)

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Completed 6 January 2022

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