Dated 05/12/20 Disclaimer: County’s recommended form; may be replaced as State documents become available.
Business Name: ________________________________________ Business Sector: _______________________________
Facility Address: _______________________________________________________________________________________
Contact the following person with any questions or comments about this protocol:
Business Contact Person: ______________________________ Phone Number: _______________________________
Prior to reopening, businesses owners or managers must complete and sign this COVID-19 Self-Evaluation
& Certification form for each facility. By signing this form, the business owner/manager acknowledges the
need to comply with the State’s Resilience Roadmap and to implement all applicable State guidance
documents to help workplaces reopen and operate safely. Businesses must retain a copy of this completed
and signed form on-site at all facilities or business locations and provide to County or City officials upon
Detailed information regarding the State’s Resilience Roadmap and all State guidance that has been issued
for each business sector is available at:
at Business
Category of State Requirements and/or Guidance
(review State details:
Notes if related measures not
fully implemented
Yes No
Performed a detailed risk assessment and
implement a site-specific protection plan in
accordance with the State guidance documents
issued for my business sector.
Yes No
Train employees on how to limit the spread of
COVID-19, including how to screen themselves for
symptoms and stay at home if they have any of the
Yes No
Implement individual control measures and
screening processes as defined by the State.
Yes No
Implement cleaning and disinfecting protocols.
Yes No
Implement social/physical distancing guidelines.
The undersigned hereby self-certifies that my business has or will implement applicable measures detailed checked
above and any applicable State guidance documents issued for my business sector, or I have noted why any
measure that is not implemented is inapplicable to my business:
Signature: ____________________________________________________ Date: ___________________________________
Name: ________________________________________________________ Phone: _________________________________
Role/Position with Business: ______________________________________________________________________________