COVID-19 Officer - Construction Safety Assessment

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This checklist is based on the State of Massachusetts' COVID-19 Employee Health, protection, guidance and prevention document. All construction activity is required to fully comply. Each COVID officer is to complete this checklist daily for each project under their purview. The COVID-19 Officer shall certify that the contractor and all subcontractors are in full compliance with these guidelines. Once complete, submit this form and it will be shared with the appropriate Planning, Design, and Construction's and/or Facilities' teammates. For reference, the provisions of the order are found here: https://www.mass.gov/info-details/covid-19-employee-health-protection-guidance-and-prevention

Email *

Name *

Date *

YYYY

Cell Phone Number *

Name of Project *

Location of Project (Building/Floor/Room as Applicable) *

How many workers on the job site (maximum)? *

Are daily self-attestations being reported? In what format? *

Yes

Daily form per employee

Daily sign in sheet with attestation check boxes

Other:

Name of supervisor responsible for recording self-attestations of health on this project: *

Cell phone number of supervisor responsible for recording self-attestations of health on this project: *

Please indicate violations of the self certification process by company name: *

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