Fillable NY FORWARD SAFETY PLAN TEMPLATE (New York State)

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NY FORWARD SAFETY PLAN TEMPLATE (New York State)

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STAY HOME. STOP THE SPREAD. SAVE LIVES.
NY FORWARD SAFETY PLAN TEMPLATE
Industry:
Address:
Contact Information:
Owner/Manager of Business:
Human Resources Representative and Contact Information, if applicable:
I. PEOPLE
A. Physical Distancing. To ensure employees comply with physical distancing requirements, you agree
that you will do the following:
Ensure 6 ft. distance between personnel, unless safety or core function of the work activity requires
a shorter distance. Any time personnel are less than 6 ft. apart from one another, personnel must
wear acceptable face coverings.
Tightly confined spaces will be occupied by only one individual at a time, unless all occupants are
wearing face coverings. If occupied by more than one person, will keep occupancy under 50% of
maximum capacity.
Each business or entity, including those that have been designated as essential under Empire State
Development's Essential Business Guidance, must develop a written Safety Plan outlining how its workplace
will prevent the spread of COVID-19. A business may fill out this template to fulfill the requirement, or may
develop its own Safety Plan. This plan does not need to be submitted to a state agency for approval but
must be retained on the premises of the business and must made available to the New York State
Department of Health (DOH) or local health or safety authorities in the event of an inspection.
Business owners should refer to the State’s industry-specific guidance for more information on how to safely
operate. For a list of regions and sectors that are authorized to re-open, as well as detailed guidance for each
sector, please visit: forward.ny.gov. If your industry is not included in the posted guidance but your
businesses has been operating as essential, please refer to ESD's
Essential Business Guidance and adhere
to the guidelines within this Safety Plan. Please continue to regularly check the New York Forward site for
guidance that is applicable to your business or certain parts of your business functions, and consult the state
and federal resources listed below.
COVID-19 Reopening Safety Plan
Name of Business:
STAY HOME. STOP THE SPREAD. SAVE LIVES.
Post social distancing markers using tape or signs that denote 6 ft. of spacing in commonly used
and other applicable areas on the site (e.g. clock in/out stations, health screening stations)
Limit in-person gatherings as much as possible and use tele- or video-conferencing whenever
possible. Essential in-person gatherings (e.g. meetings) should be held in open, well-ventilated
spaces with appropriate social distancing among participants.
Establish designated areas for pick-ups and deliveries, limiting contact to the extent possible.
List common situations that may not allow for 6 ft. of distance between individuals. What measures
will you implement to ensure the safety of your employees in such situations?
How you will manage engagement with customers and visitors on these requirements (as applicable)?
How you will manage industry-specific physical social distancing (e.g., shift changes, lunch breaks)
(as applicable)?
II. PLACES
A. Protective Equipment. To ensure employees comply with protective equipment requirements, you
agree that you will do the following:
Employers must provide employees with an acceptable face covering at no-cost to the employee
and have an adequate supply of coverings in case of replacement.
What quantity of face coverings – and any other PPE – will you need to procure to ensure that
you always have a sucient supply on hand for employees and visitors? How will you procure
these supplies?
STAY HOME. STOP THE SPREAD. SAVE LIVES.
Face coverings must be cleaned or replaced after use or when damaged or soiled, may not be
shared, and should be properly stored or discarded.
What policy will you implement to ensure that PPE is appropriately cleaned, stored, and/or discarded?
Limit the sharing of objects and discourage touching of shared surfaces; or, when in contact with
shared objects or frequently touched areas, wear gloves (trade-appropriate or medical); or, sanitize
or wash hands before and after contact.
List common objects that are likely to be shared between employees. What measures will you
implement to ensure the safety of your employees when using these objects?
B. Hygiene and Cleaning. To ensure employees comply with hygiene and cleaning requirements, you
agree that you will do the following:
Adhere to hygiene and sanitation requirements from the Centers for Disease Control and Prevention
(CDC) and Department of Health (DOH) and maintain cleaning logs on site that document date, time,
and scope of cleaning.
Who will be responsible for maintaining a cleaning log? Where will the log be kept?
Provide and maintain hand hygiene stations for personnel, including handwashing with soap, water,
and paper towels, or an alcohol-based hand sanitizer containing 60% or more alcohol for areas
where handwashing is not feasible.
Where on the work location will you provide employees with access to the appropriate hand
hygiene and/or sanitizing products and how will you promote good hand hygiene?
STAY HOME. STOP THE SPREAD. SAVE LIVES.
Conduct regular cleaning and disinfection at least after every shift, daily, or more frequently as
needed, and frequent cleaning and disinfection of shared objects (e.g. tools, machinery) and
surfaces, as well as high transit areas, such as restrooms and common areas, must be completed.
What policies will you implement to ensure regular cleaning and disinfection of your worksite and
any shared objects or materials, using products identified as eective against COVID-19?
C. Communication. To ensure the business and its employees comply with communication requirements,
you agree that you will do the following:
Post signage throughout the site to remind personnel to adhere to proper hygiene, social distancing
rules, appropriate use of PPE, and cleaning and disinfecting protocols.
Establish a communication plan for employees, visitors, and customers with a consistent means to
provide updated information.
Maintain a continuous log of every person, including workers and visitors, who may have close
contact with other individuals at the work site or area; excluding deliveries that are performed with
appropriate PPE or through contactless means; excluding customers, who may be encouraged to
provide contact information to be logged but are not mandated to do so.
Which employee(s) will be in charge of maintaining a log of each person that enters the site
(excluding customers and deliveries that are performed with appropriate PPE or through contactless
means), and where will the log be kept?
If a worker tests positive for COVID-19, employer must immediately notify state and local health
departments and cooperate with contact tracing eorts, including notification of potential
contacts, such as workers or visitors who had close contact with the individual, while maintaining
confidentiality required by state and federal law and regulations.
If a worker tests positive for COVID-19, which employee(s) will be responsible for notifying state and
local health departments?
STAY HOME. STOP THE SPREAD. SAVE LIVES.
III. PROCESS
A. Screening. To ensure the business and its employees comply with protective equipment requirements,
you agree that you will do the following:
Implement mandatory health screening assessment (e.g. questionnaire, temperature check) before
employees begin work each day and for essential visitors, asking about (1) COVID-19 symptoms in
past 14 days, (2) positive COVID-19 test in past 14 days, and/or (3) close contact with confirmed or
suspected CO
VID-19 case in past 14 days. Assessment responses must be reviewed every day and
such review must be documented.
What type(s) of daily health and screening practices will you implement? Will the screening be done
before employee gets to work or on site? Who will be responsible for performing them, and how will
those individuals be trained?
If screening onsite, how much PPE will be required for the responsible parties carrying out the
screening practices? How will you supply this PPE?
B. Contact tracing and disinfection of contaminated areas. To ensure the business and its employees
comply with contact tracing and disinfection requirements, you agree that you will do the following:
Have a plan for cleaning, disinfection, and contact tracing in the event of a positive case.
In the case of an employee testing positive for COVID-19, how will you clean the applicable
contaminated areas? What products identified as eective against COVID-19 will you need and how
will you acquire them?
In the case of an employee testing positive for COVID-19, how will you trace close contacts in the
workplace? How will you inform close contacts that they may have been exposed to COVID-19?
STAY HOME. STOP THE SPREAD. SAVE LIVES.
IV. OTHER
Please use this space to provide additional details about your business’s Safety Plan, including
anything to address specific industry guidance.
Staying up to date on industry-specific guidance:
To ensure that you stay up to date on the guidance that is being issued by the State, you will:
Consult the NY Forward website at forward.ny.gov and applicable Executive Orders at
governor.ny.gov/executiveorders on a periodic basis or whenever notified of the availability of
new guidance.
STAY HOME. STOP THE SPREAD. SAVE LIVES.
State and Federal Resources for Businesses and Entities
As these resources are frequently updated, please stay current on state and federal guidance issued in
response to COVID-19.
General Information
New York State Department of Health (DOH) Novel Coronavirus (COVID-19) Website
Centers for Disease Control and Prevention (CDC) Coronavirus (COVID-19) Website
Occupational Safety and Health Administration (OSHA) COVID-19 Website
Workplace Guidance
CDC Guidance for Businesses and Employers to Plan, Prepare and Respond to Coronavirus
Disease 2019
OSHA Guidance on Preparing Workplaces for COVID-19
Personal Protective Equipment Guidance
DOH Interim Guidance on Executive Order 202.16 Requiring Face Coverings for Public and
Private Employees
OSHA Personal Protective Equipment
Cleaning and Disinfecting Guidance
New York State Department of Environmental Conservation (DEC) Registered Disinfectants of COVID-19
DOH Interim Guidance for Cleaning and Disinfection of Public and Private Facilities for COVID-19
CDC Cleaning and Disinfecting Facilities
Screening and Testing Guidance
DOH COVID-19 Testing
CDC COVID-19 Symptoms
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NY FORWARD SAFETY PLAN TEMPLATE (New York State)

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Completed 15 March 2021

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