COVID-19 Interview Form Checklist

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COVID-19 Interview Form is used to record the details of employee who has COVID-19 symptoms and currently not at the work place. The employee who was coming to place of work later had COVID-19 symptoms and stopped coming to work place should go through this interview. This is conducted to check if he/she is tested positive for COVID-19 and to note the employees he/she had close contact with on last working day at work place. If he/she is having the infection, those in contact will be tracked and asked to quarantine. Tools and equipments used by him will be sanitized.

General

Is everyone wearing gloves?

Yes No Na

Inspection area

Location

Area Id

Is the hand wash area clean?

Yes No Na

Does the area have soap and single-use napkins?

Yes No Na

Is sanitizing solution available in all areas?

Yes No Na

Is sanitizer concentration as per the need?

Yes No Na

Is hand sanitizer stocked up?

Yes No Na

Is hand wash direction displayed?

Yes No Na

Is hand washed properly?

Yes No Na

Are employees wearing a hair covering caps?

Yes No Na

Is the hand wash sink used for washing hands?

Yes No Na

Are nails trimmed and clean?

Yes No Na

Are employees wearing minimal accessories or jewelry?

Yes No Na

Are employees eating and drinking in the work area?

Yes No Na

Are employees wearing a proper uniforms?

Yes No Na

Are employees covering their faces while sneezing or coughing?

Yes No Na

Are all wearing proper PPE?

Yes No Na

Are injuries properly bandaged?

Yes No Na

Are proper industry shoes worn?

Yes No Na

Are eye protections worn if necessary?

Yes No Na

Are industry gloves worn when dealing with heavy items?

Yes No Na

Sign off

Employee interviewed

Supervisor of the unit -name

Supervisor of the unit -signature

SIGNATURE

Date

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