COVID-19 Prevention Plan Hazard Survey

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All persons, regardless of symptoms or negative COVID-19 test results, will be considered potentially infectious. Particular attention will be paid to areas where people may congregate or come in contact with one another, regardless of whether employees are performing an assigned work task or not.
Evaluation of potential workplace exposure will be to all persons at the workplace or who may enter the workplace, including coworkers, employees of other entities, members of the public, customers or clients, and independent contractors. We will consider how employees and other persons enter, leave, and travel through the workplace, in addition to addressing fixed work locations.

Please provide name(s) of Employees and Authorized Employee Representative that Participated or were Responsible for the Hazardous Situation(s): *

Please describe the interaction, area, activity, work task, process, equipment and material that potentially exposes employees to COVID-19 hazard. *

Please indicate that last date an incident occurred.

YYYY

Please indicate the estimated time of that occurrence.

Time

Describe the Potential for COVID-19 exposures and employees affected, including members of the public and employees of other employers.

Describe the Existing and/or additional COVID-19 prevention controls, including barriers, partitions and ventilation that were present when the situation occurred.

Would you like to remain anonymous in this process?

Yes

No (If you select no, your next screen will an option for including your name.)

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