Covid-19 Workplace Safety Checklist Form
Employee Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please fill in
the COVID-19 Safety Checklist down below daily before your shift.
1. Are you experiencing symptoms like fever, cough, difficulty breathing, etc. today?
Yes
No
2. Do you wash your hands frequently in accordance with the CDC guidelines?
Yes
No
3. Do you use hand sanitizers frequently?
Yes
No
4. Do you have your own protective equipment such as masks, gloves, etc. and is your equipment clean?
Yes
No
5. Do you receive new protective equipment at the beginning of your shift?
Yes
No
6. Do you dispose used masks and gloves in designated waste bins?
Yes
No
7. Do you practice social distancing in the workplace?
Yes
No
8. Do you keep your workplace equipment clean and wiped down?
Yes
No
9. Do you recognize anyone in the workplace who actually shouldn't be?
Yes
No
10. Do you keep your working clothes clean every day?
Yes
No
11. If you have any other concerns or comments about the COVID-19 safety precautions in the workplace, please write down.
Employee Signature
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: