COVID-19 Compliance Report Form
Reporting Person
First Name
Last Name
Job Title
Date & Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please check if each of the following conditions is ensured for COVID-19 safety.
1. Is everybody wearing a mask in this place?
Yes
No
2. Are social distancing rules being applied in this place?
Yes
No
3. Are there enough hand sanitizers in this place?
Yes
No
4. Is this place being disinfected everyday?
Yes
No
5. Is there a thermometer for people to take their temperatures regularly?
Yes
No
6. Is there a QR code check-in system traced by the National Health Service?
Yes
No
COVID-19 compliance related photos/files of this place:
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Additional Comments
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