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2. Business Information
4. Business Name*
6. Business Address*
8. Owner/Manager of Business*
10. Phone Number*
11. Email*
15. I. Social Distancing
17. A. To ensure employees comply with social distancing requirements, you agree to do the following:
19. Ensure 6 ft. distancing between personnel unless safety or core function of the work activity requires a shorterdistance. Any time personnel are less than 6 ft. apart from one another, personnel must wear acceptable face coverings.

    1. Yes

    1. No
21. Ensure 6 ft. distancing between customers.

    1. Yes

    1. No
23. Post social distancing markers using tape or signs that imply 6 ft. of spacing in common areas and other areas such as clock in/out stations, cashier areas, etc.

    1. Yes

    1. No
25. Establish designated areas for pick-ups and deliveries, limiting contact to the extent possible. B.List

    1. Yes

    1. No
27. B. List some common situations that may not allow for 6 ft. of social distancing between individuals.
29. What measures will you apply to ensure the safety of your employees and customers in such situations?
31. C. How will you manage interactions between customers and visitors for social distancing requirements (as applicable)?
33. D. Describe where customers will wait for a table or for to-go-orders?
35. Is a reservation process used to help prevent people from gathering?

    1. Yes
    2. No
37. If no, explain:
39. F. How will you manage social distancing during shift changes, lunch breaks, etc.?
43. II. Personal Protective Equipment (PPE)
45. A.To ensure employees comply with protective equipment requirements, you agree to do the following:
47. We will provide employees with an acceptable face covering at no cost to the employee and have an adequate supplyof coverings in case of replacement.

    1. Yes

    1. No
49. Face coverings will be cleaned or replaced after use or when damaged or soiled, may not be shared and should be properly stored or discarded.

    1. Yes

    1. No
51. Limit the sharing of objects and discourage touching of shared surfaces; or when in contact with shared objects or frequently touched areas, wear gloves, sanitize or wash hands before and after contact.

    1. Yes

    1. No
53. B. What quantity of face coverings- and any other PPE- will you need to get to ensure that you always have a large enough supply on hand for all employees and customers? How will you get these supplies?
55. C. What policy will you implement to ensure that PPE is appropriately cleaned, stored, and/or discarded?
57. D. List some common objects that are likely to be shared between employees and customers.
59. What measures will you apply to ensure the safety of your employees and customers when using these objects?
63. III. Hygiene and Cleaning
65. A.To ensure employees comply with hygiene and cleaning requirements, you agree to do the following:
67. Adhere to hygiene and sanitation requirements from the Centers for Disease Control and Prevention (CDC) andDepartment of Trade and Consumer Protection (DATCP) and maintain cleaning logs on site that document date, time, and scope of cleaning.

    1. Yes

    1. No
69. Provide and maintain hand hygiene stations for personnel and customers, including handwashing with soap, water and paper towels, or an alcohol-based hand sanitizer containing 60% or more alcohol for areas where handwashing is not feasible.

    1. Yes

    1. No
71. Conduct regular cleaning and disinfection at least after every shift, daily, or more frequently as needed, and frequent cleaning and disinfection of shared objects (ex. Utensils, condiments, menus) and surfaces, as well as high traffic areas, such as restrooms and common areas must be completed.

    1. Yes

    1. No
73. B. Who will be responsible for maintaining a cleaning log? Where will the log be kept?
75. C. Where at the business will you provide employees and customers with the appropriate hand hygiene and/or sanitizing products and how will you promote good hand hygiene?
77. D. What policies will be implemented to ensure regular cleaning and disinfection of the areas in your business? What products are you using that are effective against COVID-19?
81. IV. Communication
83. A. To ensure the business and its employees comply with the communication requirements you agree to do the following:
85. Post signage throughout the business to remind personnel and customers to adhere to proper hygiene, socialdistancing requirements, proper use of PPE, and cleaning and disinfecting protocols.

    1. Yes

    1. No
87. Consistently inform employees and customers of any updated changes to policy and/or procedures.

    1. Yes

    1. No
89. If a worker tests positive for COVID-19, employers will immediately notify the local health department and cooperate with contact tracing efforts, including notification of potential contacts, such as workers or customers who came in close contact with the individual, while maintaining confidentiality required by state and federal law regulations.

    1. Yes

    1. No
91. B. If a worker tests positive for COVID-19, which employee(s) will be responsible for notifying the West Allis Health Department? Who will be responsible for identifying and contacting tracing those who may have been exposed?
95. V. Process
97. A. Screening. To ensure the business and its employees comply with screening requirements, you agree to do the following:

    Implement mandatory COVID-19 screening (e.g. questions, temperature checks) before employees begin work each day and for essential visitors, asking about (1) COVID-19 Symptoms in the past 14 days. (2)

    1. Yes

    1. No
99. What type(s) of daily health and screening practices will you implement? Will the screening be done before the employee starts work or on site? Who will be responsible for performing them, and how will those individuals be trained?
101. If screening is onsite, how much PPE will be required for the responsible parties carrying out the screening practices? How will you supply the PPE?
103. B. Testing. Individuals who carry the COVID-19 virus may or may not have symptoms. Testing helps to identify those with the virus. To help control the spread of disease, testing is important. The objective is a sustainable system of screening, and testing identifies ill employees. Do you require or recommend employees be tested for COVID-19?

     Please check one:

     1. Require

     1. Recommended

     1. Neither
105. If required, how frequently?
107. If recommended, under what circumstances?
109. C. Contact tracing and disinfection of contaminated areas due to exposure. To ensure the business and its employees comply with contact tracing and disinfection requirements, you agree that you will do the following:

     1. Have a plan for cleaning, disinfection, and contact tracing in the event of a positive case.

     .
111. In the case of an employee who tests positive for COVID-19, how will you clean areas that have been contaminated? What products that are effective against COIVD-19 will you use and how will you acquire them?
113. In the case of an employee who tests positive for COVID-19, how will you inform close contacts in the workplace? How will you inform close contacts that they may have been exposed to COVID-19?
117. VI. Other
119. A. Please use this space to provide any additional details about how your business’s Safety Plan, including anything to address specific to your business.
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121. 1. Receive an email copy of this form.
122. Email address

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