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COVID-19 Exposure Control Plan YES Progress NO N/A

1. Has the employer deployed a safety and health committee or other forum for frontline workers and other key stakeholders toparticipate
in the development of the COVID-19 exposure control plans?

2. Has the employer developed a written COVID-19 Exposure Control Plan?

3. Has the employer conducted a Job Hazard/Safety Analysis for each position?

4. Has the employer put the most effective method(s) for minimizing exposure to SARS CoV-2 in place?

5. Are employees encouraged to speak up, without fear of retaliation, if they have safety and health concerns or if they observeviolations
of employer policies and procedures?

6. Is there a formal process for employees to file complaints and offer suggestions?

7. Has the employer provided communications and training on the following:

a. Self-reporting expectations?

b. Safety and health protocols and control measures?

c. Information on the virus and how it is transmitted in advance of work?

8. Other?

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Measures to Maintain Social Distancing YES Progress NO N/A

1. Has the employer placed signage at each entrance of the facility to inform all employees, customers, and visitors of thethat they:

a. Shall not enter the facility if they have a cough or fever?

b. Shall maintain a minimum six-foot distance from one another?

c. Shall practice respiratory etiquette when inside?

2. Is all signage readable, clear, and presented in language(s) consistent with those spoken in the workplace and community?

3. Are signage or barriers in place inside the building to help maintain 6 feet of separation?

4. Has the organization established a maximum occupancy and enforceable procedure to ensure a minimum of 6 feet distancebetween
employees, customers, and visitors?

5. Has the employer modified the workplace and work practices to ensure at least 6 feet of physical distancing?

6. Are markings or barriers in place to establish one-way directional traffic inside facilities to prevent choke points (bottlenecks)?

7. Are there controls in place to prevent congestion in elevators, stairways, restrooms, meeting and training rooms, lockerrooms,
break rooms, cafeterias, and transport services?

8. Has the employer notified personnel to avoid carpooling?

9. Has the employer provided direction to workers on how to protect themselves when 6 feet of physical distancing is not
maintained?

10. Other?

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Engineering Controls YES Progress NO N/A

1. Has the employer adjusted the heating ventilation and air conditioning (HVAC) system so that it maximizes ventilation(dilution of
air)?

2. Has the employer maximized the use of technology to minimize face to face interactions?

3. Have select doors been bypassed to decrease touching of push bars and handles, consistent with security and fire safety
requirements (e.g., automatic doors or separate entrance and exit)?

4. Has the employer considered eliminating use of time clocks and other devices that cause a gathering of where it is difficult tomaintain
social distancing of employees?

5. Have employers with residents such as corrections, nursing, and long-term care, and other institutions, developed procedures for
early identification and isolation of people who are suspected or known to have COVID-19 in negative airpressure isolation
rooms?

a. If negative air pressure isolation rooms are not available, have procedures been established to quickly and safelytransport
people to healthcare facilities that do have them?

6. Have workers who transport people with suspected or known COVID-19 been trained to do the following:

a. Open windows for maximum air circulation?

b. Set the vehicle to outside air circulation?

c. Use PPE and respiratory protection

7. Other?

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Work Practices YES Progress NO N/A

1. Has the employer ceased all non-essential travel?

2. Has the employer put a process in place to vet the necessity of travel if it is required?

3. Has the employer established a policy enabling employees perform their jobs remotely (i.e., telework)?

4. Has the employer implemented zero or minimal customer contact procedures, such as online or telephone ordering andcurbside
pickup?

5. Have work shifts and break times been staggered to reduce choke points (bottleneck) and congestion?

6. Have conference rooms and break area furnishings (tables, chairs, desks) been adjusted to maintain physical distancing?

7. Have self-service tasks previously performed by customers been discontinued, such as allowing customers to handle lids forcups, food-
bars (buffet), and self-checkout?

8. If self-checkout is in place, is there a process for surface cleaning/disinfection between each use?

9. Have contactless payment systems been established, or, if not feasible, procedures established for sanitizing paymentequipment
between each use?

10. Has the employer suspended allowing customers to bring their own bags, mugs, or other reusable items?

11. Has the employer erected physical barriers such as plexiglass or windows, or employed other means to separate customersand
employees?

12. Has the employer banned the sharing of headsets and other objects that are used near the eyes, nose, and mouth?

13. Are customers and employees required to wear face covering to reduce spread of the SARS-CoV-2 virus?

14. Other?

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Enhanced Cleaning and Disinfection In
YES Progress NO N/A

1. Are handwashing facilities available to all employees with soap and running water?

2. Are alcohol-based hand sanitizers available to all employees, at entrances and exits, and field locations and regularly
maintained?

3. Has the organization developed a cleaning and disinfection schedule that includes the following:

a. A routine enhanced cleaning/disinfection schedule.

b. Employees trained and assigned to perform cleaning/disinfection tasks, including information on product contact time.

c. Use of PPE and safe work practices to prevent chemical exposures.

d. Availability of cleaning supplies and EPA-registered disinfectants effective against the SARS CoV-2 virus.

e. Consideration of less toxic disinfectants that minimize health risks (e.g., green cleaning alternatives).

f. Identified “high touch” surfaces such as tables, chairs, doorknobs, light switches, handles, desks, toilets for frequentsurface cleaning
and disinfection.

g. Identified shared equipment such as phones, pens, keyboards, touch screens, and remote controls and processes forcleaning and
disinfection.

h. Enhanced cleaning and disinfection procedures when there is a suspected or known exposure to a personwith COVID-
19.

i. Disinfectants available for customers/visitors near items they touch, such as pre-moistened wipes.

j. Employee(s) assigned to regularly disinfect items touched by customers.

4. Other?

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Personal Protective Equipment (PPE) and Respiratory Protection In
YES Progress NO N/A

1. Has the employer conducted a hazard assessment to determine the type of PPE that should be used, and for whichjob tasks?

2. Does the employer have a sufficient inventory of PPE, provided at no cost to employees, such as gloves, eye protection,protective
clothing, and respirators?

3. Has the employer conducted a respiratory hazard assessment to determine the nature of and magnitude of respiratoryhazards in
the workplace?

4. Has the employer developed a written respiratory protection program that complies with OSHA requirements, includingmedical
clearance, respirator selection, and fit testing?

5. Has the employer trained workers on the proper use, donning, doffing, disposal and/or decontamination of PPE and
respirators?

6. Does the employer have a process for changing/laundering work uniforms?

7. Other?

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Sick Leave, Symptom Screening, and Employee Health In
YES Progress NO N/A

1. Has the organization clearly communicated that employees are not to come to work if sick?

2. Have all employees been notified to report if they have symptoms of COVID-19 including fever, coughing, shortness of break,loss of
smell, taste or gastrointestinal symptoms (diarrhea and nausea)?

3. Has the employer directed that infected/sick employees should home isolate for 14 days and not return to work until they aresymptom
free and have had a normal temperature for 3 consecutive days without the use of fever-reducing medication?

4. Does the employer have a process in place to assess employees that have an ill person in their household?

5. Are all employees screened for symptoms before entering the workplace?

6. Has the organization established a paid sick leave policy for all employees as recommended by CDC?

7. Does the sick leave policy allow employees to stay away from work to provide care to family members?

8. Has the employer established a policy to protect high-risk employees, including those over 65 years old and with pre-
existing/underlying chronic medical conditions?

9. Other?

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Exposures and Case Reporting In
YES Progress NO N/A

1. Has the employer established a procedure for employees to report exposures occurring at work or in the community?

2. Does the exposure procedure include home isolation for 14 days?

3. Does the exposure procedure include cleaning and disinfection of potentially contaminated areas?

4. Has the organization developed a return-to-work policy for employees that have tested positive and/or recovered fromCOVID-19
like illness?

5. Has the employer suspended the requirement for employees who are in home isolation to provide medical documentation toreturn to
work, as recommended by CDC?
Note: This is so that people in home isolation that do not have symptoms or who have low level symptoms DO NOT go to the emergencyroom or their
primary provider.

6. Has the employer developed a process for contact tracing when an employee tests positive or becomes symptomaticwith
COVID-19?

7. Has the employer established a relationship with the local, county, and state health department to coordinate case reportingand
contact tracing?

8. Has the employer developed a process for informing employees when they have been exposed to a person suspected orconfirmed
to have COVID-19?

9. Other?

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Measures to Protect Employee Mental Health and Physical Well-Being In
YES Progress NO N/A

1. Has the employer developed a program to address the psychological well-being of employees?

2. Does the employer provide access to an employee assistance program?

3. Does the employer provide adequate mental health benefits?

4. Does the employer have a process where employees can confidentiality report when they are experiencing job and life stresswithout fear
of retaliation?

5. Are there work factors that contribute to employee stress and fatigue that should be addressed?

6. Does the organization help employees to maintain their psychological and physical health?

7. Other?

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