Cleaning Staff Entry Authorization Consent Form
Please complete this form to request and authorize entry for cleaning staff. All information is required to ensure safety and proper record keeping.
Full Name of Cleaning Staff
*
First Name
Last Name
Staff Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Email Address
*
example@example.com
Company/Agency Name (if applicable)
Staff ID or Employee Number
*
Date and Time of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Area(s) or Room(s) to be Accessed
*
Purpose of Entry
*
Please Select
Routine Cleaning
Deep Cleaning
Disinfection
Emergency Cleaning
Other
Duration of Entry (estimated)
*
Please Select
Up to 30 minutes
31-60 minutes
1-2 hours
More than 2 hours
Supervisor or Contact Person on Site
*
Emergency Contact Name and Number
List any equipment or materials to be brought in (if any)
Signature of Cleaning Staff or Authorized Representative
*
Submit Authorization
Submit Authorization
Should be Empty: