Health and Safety Reporting Form
This form is a follow up to the walkthrough (bit.ly/UESFWalkthrough). Complete this form so that we can work collectively to push district management to address issues that are affecting multiple sites. Complete this form as many times as needed.

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Name (First, Last) *
Email *
Phone Number
Work Site *
Today's Date *
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On a scale of 1-5, please let us know how well the health and safety protocols are being enforced at your worksite:
health and safety protocols are actively being enforced
health and safety protocols are not being enforced
Clear selection
Was the UBC involved in the process of generating clear protocols for the site?
Clear selection
On a scale of 1-5, how collaborative has your administration been with the UBC in establishing and implementing safety protocols
the administration has not been collaborative with the UBC
the administration has been highly collaborative with the UBC
Clear selection
Site Procedures
Is the designated on-site COVID 19 liaison identified?
Clear selection
Is the isolation room clearly designated?
Clear selection
Are standardized responses with clear alternate educational opportunities for students who struggle with mask wearing documented?
Clear selection
Have responses with clear alternate educational opportunities for students who struggle with mask wearing been communicated to staff, students and families?
Clear selection
Are agreed upon safe lunch procedures documented?
Clear selection
Have agreed upon safe lunch procedures been communicated to staff and students?
Clear selection
Are agreed upon requirements and expectations for staff meetings documented?
Clear selection
Are agreed upon requirements and expectations for meetings communicated to staff?
Clear selection
Are agreed upon requirements and expectations for family meetings and events documented?
Clear selection
Have agreed upon requirements and expectations for family meetings and events communicated to staff and families?
Clear selection
Are outdoor spaces organized to maximize usage? 
Clear selection
PPE & Hygiene & Ventilation
Are masks stocked and available for staff and students?
Clear selection
Is masking signage clearly displayed in all areas?
Clear selection
Please check off the modes of ventilation you are aware of that are currently working properly in your work area.
Please check off the modes of ventilation that are currently **not** working properly in your work area.
How many multi-occupancy rooms are there on campus?
Do rooms without functioning windows or mechanical ventilation have appropriate portable air cleaners installed?
Clear selection
Each multi-occupancy room have a) functioning windows, and/or b) a portable air cleaner, and/or c) mechanical ventilation
Clear selection
If ALL multi-occupancy room do not have a) functioning windows, and/or b) a portable air cleaner, and/or c) mechanical ventilation, please indicate how many rooms do NOT have required ventilation
Clear selection
Check off the adequate supplies of the following items that support healthy hygiene behaviors are stocked on site including
Please let us know here about any other questions, concerns, or ideas you might have about how we can ensure SAFE school and work places for ALL. If you would like to support and be involved in these efforts, let us know! *
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