Workplace Safety and Concerns Form
Name (optional)
First Name
Last Name
Department
Position
Do you think you are in close contact with one another (within about 6 feet).
Yes
No
Do you have any individual risk factors?
Older age
Presence of chronic medical conditions
Including immune compromising conditions
Pregnancy
Other
Do you have any concerns about basic infection prevention measures?
Rows
Yes
No
Any comments?
Hand Washing
1
2
Workers are staying home if they are sick
3
4
Respiratory etiquette including covering coughs and sneezes
5
6
Physical distance among employees
7
8
Using of other workers’ phones, desks,
offices, or other work tools and equipment
9
10
Regular housekeeping practices
11
12
Do you need any training about COVID-19?
Yes
No
Other
Do you have any concerns about:
Rows
Yes
No
Comments
Pay
13
14
Leave
15
16
Safety
17
18
Health
19
20
Other (please specify)
21
22
Do you think we need any improvements in engineering controls?
Rows
Yes
No
Any thoughts?
Air filters
23
24
Ventilation rates in the work environment.
25
26
Do you have any additional concerns or comments?
Submit
Should be Empty: