La Mar San Francisco 

 
Employee Health & Sanitation 
Guidelines 
 
 
MAY 2020 
 
 
 
 

Pier 1 1/2 The Embarcadero | San Francisco, CA 94111 

  

La Mar San Francisco 

Health & Sanitation Program 2020 

 
TABLE OF CONTENTS 
General Requirements   
Introduction  2 
Employee’s Responsibilities  3 
Employee & Guest Health  6 
Cleaning Products & Protocols    7 
Physical Distancing  8 
Procurement of PPE  9 
 
   
Department-Specific Sanitization Policies   

FOH & BOH Sanitization Policy  10 

COVID-19 Symptom & Illness Reporting Policy  13 
COVID-19 Self Reporting Questionnaire  15 
Employee Health & Sanitization Guideline Agreement  16 
 

 
 

 
We are closely monitoring government policy changes, Centers for Disease Control 
(CDC) guidelines, government mandates, and public health advancements and will 
continue to make changes as necessary or appropriate to our protocols and 
procedures. 

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Introduction 
Hello and welcome back to La Mar. In light of the COVID-19 pandemic, we are taking proactive steps 
to address a number of concerns. Our top priority is to maintain a safe workplace and support 
practices to protect your health and the health of our co-workers, guests, customers, and others.  

We are working with our vendors to ensure an uninterrupted supply of cleaning supplies and the 
necessary Personal Protective Equipment (“PPE”) to support your health and our safety efforts. As a 
method to track and limit exposure to multiple co-workers, we are assigning designated teams to 
corresponding schedules - Team A (AM Shift) & Team B (PM Shift). 

We ask all employees to cooperate in taking steps to reduce the transmission of communicable 
diseases by complying with the policies and procedures set forth in this guideline. It is your 
responsibility as an employee to maintain your health and monitor and report any signs of symptoms 
for the sake of your family’s health as well as our guests and co-workers. 

We are in this as a team and together will come back stronger than ever. 

- Team La Mar 

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Employee’s Responsibilities 
Employees are the first line of defense for an effective health and sanitation program 

Employee Health & Safety  

With this guideline, you will find clear instructions on how to respond to all presumed or confirmed 
cases of COVID-19 infection and will be ready to provide support to our guests experiencing any 
health concerns. You are reminded to stay home if they do not feel well. Employees are also instructed 
to contact a manager if you notice that you, a coworker, or a guest have flu-like symptoms. We are 
reinforcing recommended measures on appropriate hygiene standards to minimize the risk of 
exposure to viruses following the guidance of the Centers for Disease Control and Prevention (CDC). 

➜ ​COVID-19 Training   ➜ ​Free COVID-19 Testing 

All employees will receive training on  All employees are required to take a 
COVID-19 safety and sanitation protocols with  COVID-19 test provided for free to employees 
more comprehensive training for our teams  through CityTestSF. Schedule your 
with frequent guest contact​. All employees will  appointment and learn more here:  
be required to complete the COVID-19   
General Awareness and watch training videos.  https://sf.gov/get-tested-covid-19-citytestsf 
Training will be available in English and   
Spanish.  
 

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Team A & Team B   Symptoms & Reporting While at Work  

La Mar​ E
​ mployees will be split into two teams:  When you feel unwell with symptoms of 
Team A and Team B. You will be assigned to  COVID-19 or observe another co-worker 
one of the two teams in order to limit the  exhibiting symptoms of COVID-19 at work, 
exposure of multiple co-workers by working  you are to contact a manager immediately. A​  
separate schedules. Teams will be scheduled  private isolation interview and screening will 
as follows: Team A: AM Shift & Team B: PM  be conducted for all suspected ill employees. 
Shift 
Personal Protective Equipment (PPE) 
Hand Washing   Appropriate PPE must be worn by all  
Proper and frequent handwashing with soap is  employees. Training on how to properly use 
vital to help combat the spread of any virus. All  and dispose of all PPE will be provided. Every 
employees must wash or sanitize their hands  employee entering the restaurant will be 
frequently (for 20 seconds) and after any of  provided a mask and, except as otherwise 
the following activities: using the restroom,  provided in these guidelines, will be required 
sneezing, blowing the nose, cleaning,  to wear the mask and, as applicable, other PPE 
sweeping, mopping, smoking, eating, drinking,  while on property. 
entering and leaving their work station, going 
on break and before and after starting your 
shift.  

➜ ​Employee Entrance Screening Protocols: 

 
You will be asked to queue for screening while observing physical distancing protocols. Screening 
includes temperature checks on every employee before allowing access.  

1. Temperatures less than 100.4°F (38°C) will be issued a face mask and allowed to access  
2. Employees with temperatures of 100.4°F (38°C) and above will be directed to a secondary 
screening area, and will be screened after a 10 minute wait. I​ f an employee’s temperature 
remains above 100.4°F (38°C), the employee will be asked to return home and monitor their 
health condition.  
3. Employees are responsible for contacting a manager and reporting an absence.  

➜ ​Screening Interview Protocols: 

1. If you are suspected or show symptoms of COVID-19, you must complete a S ​ uspected 
COVID-19 Questionnaire Form 
2. Once completed, you will be instructed to leave work and go home or to the nearest health 
center as advised by the local health authority.  
3. In coordination with management, when reporting a suspected co-worker, you must: 
a. Identify who may have been in contact with the suspected infected employee 

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b. Employees who may have been in contact with a suspected infected employee must 
carry out a self-screening check every morning, and based on the results, contact 
management 
4. The isolation interview area and suspected infected employee’s workstation will be 
thoroughly cleaned and disinfected, in addition to all other common surfaces recently touched 
by the suspected infected employee. 

Any health or other private information collected from the ill employee must be retained securely only 
by management, and may not be shared with other employees except as permitted by law.  

COVID-19 Training  
The following videos are required for all employees to complete as part of their preparation on what to 
expect when they return to work and as La Mar resumes operations. It includes information on 
COVID-19, how it spreads, symptoms to look for, and prevention reminders including good hygiene 
practices.  
 
“​Understanding COVID-19 and How to Stay Safe” 
https://www.youtube.com/watch?v=DCdxsnRF1Fk 
 
“​Recognizing Day to Day Signs and Symptoms of Coronavirus” 
https://www.youtube.com/watch?v=U8r3oTVMtQ0 
 
Employee Reporting Procedure  
If you have been exposed to someone with known or suspected COVID-like symptoms, or suspects to 
be asymptomatic of a communicable disease/illness, the employee will be subject to mandatory or 
suggested quarantine. If you receive a report of a communicable disease/illness from a health care 
provider, you are required to notify management immediately. 

Additionally, you are to report any travel to an area that has had reports of an outbreak of COVID-19 
or has been designated by the CDC as a Level 2 & 3 area to your manager. Employees who have been 
subject to any of the above listed situations should follow the COVID-19 Symptom and Illness 
Reporting Policy and ​complete the Employee COVID-19 Self Reporting Questionnaire attached on the 
page 15. 
 
Personal Protective Equipment (PPE)  
Appropriate PPE must be worn by all employees in adherence to local, state and federal guidance. 
Training on how to properly use and dispose of all PPE will be provided. All employees entering the 
restaurant will be provided a mask and, except as otherwise provided in these guidelines, will be 
required to wear the mask and, as applicable, other PPE while on property.  

Daily Line-Up  
BOH & FOH Line-Up meetings will be conducted virtually or in areas that allow for at least six feet of 
separation between employees.  

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Employee & Guest Health 

Guest Temperature Screening   Physical Distancing  
La Mar may utilize thermal cameras placed at  Guests will be advised to practice physical 
entry points to the restaurant to conduct  distancing by remaining at least six feet away 
non-invasive temperature checks of guests.​ ​If  from other guests while standing in lines or 
such screening is conducted, anyone  moving around the property. Tables will be 
displaying a temperature over 100.4°F (38°C)  arranged to support appropriate distancing. 
will not be allowed to enter the restaurant or  You are not to touch your face and practice 
may be taken to a private area for a secondary  physical distancing by standing at least six 
screening. Guests subsequently confirmed to  feet away from guests and other employees 
have a temperature over 100.4°F (38°C) will  whenever possible. La Mar will comply with 
not be allowed entry to the property and will  local or state mandated occupancy limits, 
be directed towards appropriate medical care.   including no more than 50% occupancy in 
each dining area.  
Guest Arrival 
Guests will enter the restaurant through doors  Community Sharing  
operated by an employee wearing appropriate  While we continue to support our employee 
PPE, or via other touchless means. The door  community, shared and communal snacks, 
handles will be sanitized at regular intervals.   food and beverage are not allowed unless 
items are individually wrapped.  

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Hand Sanitizer   BOH Signage  

Hand sanitizer dispensers will be placed at key  Signage will be posted throughout the 
guest and employee contact areas such as the  property reminding employees of the proper 
lobby, entrances, bar, dining areas, break  way to wash hands, sneeze and to avoid 
areas, kitchen, restrooms, lounge and patio  touching their faces.  
spaces. Dispensers will be checked and refilled 
on a regular basis.  COVID-19 Case Notification  
If we are alerted to a case of COVID-19 at the 
FOH Signage   restaurant, we will work with the local health 
There will be health and hygiene reminders  authorities and will follow the appropriate 
throughout the property and in restrooms.  steps with any impacted guests and 
Guests will be reminded that while the  employees. We will conduct an additional 
restaurant is making every effort to keep  cleaning and disinfecting protocol of all areas 
guests and employees safe, guests are  that the guest has known to have been in 
ultimately responsible for their own hygiene  contact with during their visit. A summary of 
and safety practices, such as social distancing.   the COVID-19 Guest Case Management 
Protocol is included in this document. 
 

Cleaning Products & Protocols 

We will use cleaning products and protocols approved for use and effective against viruses, bacteria, 
and other airborne and bloodborne pathogens. Our protocols for cleaning and disinfecting are 
approved by the CDC and Occupational Safety and Health Administration (OSHA).  
 

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Designated Cleaners  High Traffic Areas  

Two employees per shift will be assigned to  Lounge and dining spaces, receiving areas, 
cleaning throughout their shifts. Cleaning will  patio, and bars have their own area-specific 
be focused on disinfecting high-touch items  cleaning guidelines and protocols beginning on 
and areas at a consistent and frequent basis.  page 9. 
 
Public Spaces & Communal Areas   Back-of-House  
The frequency of cleaning and disinfecting will  The frequency of cleaning and disinfecting will 
be increased in all public spaces including an  also increase in high-traffic back-of-house 
emphasis on frequent contact surfaces such as  areas with an emphasis on the employee 
the host stand, door handles, restrooms,  entrances, employee restrooms, break rooms, 
seating, railings, dining surfaces and  offices, kitchens, door handles, and lockers.  
restaurant menus.  
Shared Equipment  
CDC and OSHA-approved cleaning and  Shared tools and equipment must be sanitized 
disinfecting protocols are used to clean all  by the applicable employee after your shift or 
areas with particular attention paid to  transferred to a new employee. Shared 
high-touch items including toilet seats and  devices utilized for the duration of your shift 
handles, door and furniture handles, water  must be sanitized at the start and end of a 
faucet handles, telephones, light switches,  shift and when returning from a break. Shared 
temperature control panels and flooring.   tools, equipment and devices include: POS 
stations and tablets, kitchen gadgets, BOH 
Linen   tools, cleaning equipment, phones, and all 
All linen will continue to be picked up by our  other direct contact items used throughout the 
third-party vendor and replaced brand new  restaurant. 
linens on a daily basis. 

Physical Distancing 
Seating in the Main Dining Room, Cebiche Lounge, and bar will be reduced by 50% or otherwise to 
allow for appropriate distancing between each table. Employees serving food and drinks must sanitize 
their hands between every service, ideally in view of guests, so guests feel comfortable that every 
effort is being made to maintain hygiene protocols.  

Guest Queuing  
Any area where guests queue will be marked with proper distancing, including check-in, check-out, 
and lobbies.  
 
Back-of-House  
Physical distancing protocols will be used in the receiving areas, employee locker areas, prep areas, 
kitchen and other high-density areas in order to ensure proper physical distancing. In practice, this 
means:  

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● Staying six feet away from others as a normal practice 

● Eliminating physical contact with others, such as handshakes or embracing coworkers 
● Cleaning up after yourself using company provided sanitizing wipes and other cleaning 
products 
● Avoiding touching surfaces touched by others, to the extent feasible 
● Avoiding anyone who appears to be sick, or who is coughing or sneezing 

Procurement of PPE & Other Equipment 

We are centralizing the procurement of all required PPE and other equipment for all of La Mar 
employees. Please follow the proper SOPs to acquire any of the below items for your areas. If you 
have questions or believe your area requires items not specified below, please contact management.  

Infrared Temporal Thermometers    

Infrared temporal thermometers or similar 
Bottles​: Bottles of hand sanitizer will be placed 
non-invasive devices may be used to check 
the temperatures of guests and employees.   on all desks, podiums and counters where 
employee and guest interactions regularly 
Personal Protective Equipment (PPE)   occur.  
for Employees  
Sanitizing Stations​: Stations with hand 
Masks​: All employees will be provided a 
sanitizer will be located at all entrances, 
minimum of one mask for each shift.  
restrooms, lobbies, around the dining areas, 
 
entrances to restaurants and meeting rooms.  
Gloves​: All employees are required to wear 
 
gloves to perform their job duties and change 
them frequently as task standards require.   Signage  
FOH Signage​: Health and hygiene reminders 
Personal Protective Equipment (PPE)  
throughout the property and in restrooms.  
for Guests    
Appropriate PPE will be available for guests  BOH Signage​: Signage will be posted 
throughout the property. Employees should  throughout the property reminding employees 
provide reasonable PPE to any guest that  of the proper way to wash hands, sneeze and 
requests PPE.   to avoid touching their faces.  
 
Hand Sanitizer  
Queuing Signage​: Stanchions and/or floor 
Hand sanitizer dispensers will be placed 
decals will be placed to indicate appropriate 
throughout the restaurant. Dispensers will be 
queuing locations.  
regularly checked and refilled.  
 
 

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Department-Specific Sanitization Policies 

➜ ​Lobby / Host Podium 
Employee PPE & Hygiene  

● See General Requirements  

● Staff to sanitize their hands after every guest transaction  

Cleaning & Disinfecting 

● Hand sanitizing stations will be placed at host podium 

● Workstations to be sanitized by hostsesses on a regular basis 
● Supervisors to complete a log in each section to track disinfecting schedule 

Physical Distancing Protocol 

● Hostesses and managers to manage physical distancing at entries, waiting areas and queues  
● Guests to maintain six feet of separation while queueing in lobby 
● Floor staff will maintain distance from guests on floor until seating is required 

Guest Considerations  
● Sanitizing dispensers to be placed on the restaurant floor  
● Signage to be placed on the dispenser encouraging guests to sanitize before seating  
 
 

➜ ​Bar 
Employee PPE & Hygiene  

● Masks will be worn by all employees 

● Hand washing protocols in line with CDC recommendations 
● Touchless hand sanitizer dispensers to be added to service stations and employees will 
sanitize their hands after ever guest interaction 

Cleaning & Disinfecting 

● Managers to ensure sanitization protocols are being followed at appropriate intervals and log 
critical/timestamp touch points 
● POS terminals to be sanitized between uses and after each shift 
● Dining tables, bar tops, stools and chairs to be sanitized after each use with a spray 
disinfectant 
● Condiments to be served in single-use containers (either disposable or washed after each 
use) 
● Menus to be sanitized after each use or single use 
● All menus must be single-use disposable or printed on waterproof/cleanable paper 

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● Existing porous placements to be replaced with single-use disposable or non-porous 
placements that can be machine washed and sanitized after each use, or eliminated 

Physical Distancing Protocol 

● Peak period queuing procedure to be implemented when guests are not able to be seated 
immediately  
● Tables to be set to provide for appropriate social distancing between each party  
● Bar stools to be arranged to provide for appropriate social distancing  
● Monitor the line flow at quick service outlets for order and pick up to be appropriately 
distanced  
● Lounge groups not to exceed eight guests per sofa set or seating area  
● Maximum of two employees in a bar at any given time 
● Cover drinks going to tables utilizing a disposable lid if possible  

Guest Considerations  
● Touchless hand sanitizer dispenser and wipes available at each venue entrance  
● All self-serve condiments and utensils to be removed and available from cashiers  
● All straws to be wrapped and provided on request  
● Napkin service to be suspended until further notice (no placing in a guest’s lap or refolding); 
provide fresh napkin if one falls on the floor  
●  
 

➜ ​Main Dining Room / Cebiche Lounge / Patio 

Employee PPE & Hygiene  
● All employees to wear aprons and hats in addition to the general PPE requirements  
● Sanitizer stations available throughout dining room 

Cleaning & Disinfecting 

● Proper handwashing protocol followed and monitored by management  
● Kitchen cleaned and disinfected regularly with sections deep cleaned at least every 24 hours  
● Food & beverage product removed from original packaging and stored in sanitized containers 
prior to entering dining (where applicable)  
● Food prep areas cleaned and sanitized every hour and logged  
● All high touch point areas to be cleaned and sanitized after each use where applicable  
● Venue to be deep cleaned and disinfected each day by section  
● Proper and frequent handwashing by servers, bussers, and kitchen staff mandated  
● POS stations to be assigned to specific individuals and to be cleaned and disinfected on a 
regular basis prior to breaks or shift changes  
● Food trays cleaned and sanitized after each use  

Physical Distancing Protocol 

● Six feet between tables and appropriate seating floor plan established  
● Operate at 50% of dining room capacity  
● Mark floors to ensure floor plan is not altered by employees  

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● Chefs, BOH, and FOH staff to manage physical distancing at entries, waiting areas and 
queues (in additional to signage)  
● Peak period queuing procedure to be implemented when guests are not able to be served 
immediately  

Guest Considerations  
● Food to be served by bussers 
● Prepackaged plastic flatware 
 

➜ ​Kitchen / Prep 
Employee PPE & Hygiene  
● All BOH employees to wear aprons and hats (in addition to the general mask and glove 
requirements) 

Cleaning & Disinfecting 

● All food and beverage product to be handled in accordance with USDA and CDC 
recommendations 
● Storage containers to be sanitized before and after each use 
● Food preparation stations to be sanitized on a regular basis 
● Test sanitizer solution on a regular basis 
● Kitchen to be sanitized each night 

Physical Distancing Protocol 

● Kitchen staff to remain six feet from each other and guests 
 

➜ ​Reservations / Events / Administrative Offices 

Employee PPE & Hygiene  
● See General Requirements 
● Masks are not required while employees are at their workstation but should be worn in 
common areas and during necessary in-person meetings 

Cleaning & Disinfecting 

● Cleaning crew has added wiping down high touch areas (railings, door handles, etc.) 
to their procedures and increased strength of chemicals to hospital-grade 
● Shared food is not allowed unless individually packaged 
● Self-cleaning of the workspace is encouraged multiple times during the shift with special 
attention of the most used surfaces such as keyboards, monitors, chair arm rests, desks 
among others 
● Hand sanitizer and sanitizing wipes will be available in all office areas to clean person 
workspaces 
 

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Physical Distancing Protocol 

● Office work should be organized to ensure social distancing to keep separation of employees 
between three to six feet as a minimum and face-to-face desk layouts should be avoided 
● Remote work may be assigned when possible or mandated by the government 
● Outside guests and visitors should not enter administrative offices or back-of-house areas 
until further notice 
● Company or department-sponsored events are postponed until further notice 
 

COVID-19 Symptom & Illness Reporting Policy 

Purpose  
To ensure employees reporting to work with flu-like or COVID-19 symptoms are removed from the 
workplace and promptly tested to avoid potential exposure to others. Any health or other private 
information collected from employees(s) must be retained securely only by management and may not 
be shared with other employees except as permitted by law.  

Procedure  
1. Immediate notification to the management should occur when:  
a. An employee is experiencing flu-like or COVID-19 symptoms 
b. An employee has become aware that another employee is experiencing or displaying 
flu-like or COVID-19 symptoms 
c. An employee has knowledge that he or she was exposed to another individual who 
has tested positive for COVID-19 
d. An employee has become aware that another employee has knowledge that he or she 
was exposed to another individual who has tested positive for COVID-19 
2. The employee in question w ​ ill be sent to a contracted facility for testing​. After the employee 
has been tested, he or she must go home and self- isolate. It is also recommended, but not 
mandatory, that the employee contacts a healthcare provider. 
3. After any suspected or confirmed COVID-19 case, the contact-tracing protocol will be 
activated by management to determine potential exposure to other individuals. Management 
will then review 48 hours from the report to determine potential exposure to others. Potential 
exposure is defined as coming/being in contact with a suspected infected employee:  
a. within three feet for five minutes or longer 
b. within six feet for 10 minutes or longer 
4. Any impacted employee identified during contact tracing will be sent to a contracted facility 
for testing. After the employee is tested, he or she must go home and self-isolate  
5. Any impacted work areas must be sealed off and be disinfected by the external 
cleaning/sanitizing contractor.  
6. After steps 1 – 5 have been completed, where applicable, management will activate an 
interactive process:  
a. Management will contact the impacted employee(s) via phone to conduct interview(s) 
and coordinate completion of the questionnaire; and 

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b. The impacted employee(s) will be asked to complete the “COVID-19 Questionnaire 
Form” (attached, pg 15) 
7. An email notification will be sent to the department’s management with statuses of the 
impacted employee(s)  
8. Impacted employee(s) will be placed on paid a Quarantine Sick Leave until returned to work 
according to Company policies 
9. Management will continue the interactive process with affected employee(s) as more 
information is received including test results 
10. Once test results are received, the affected employee(s) must immediately notify 
management. If the impacted employee(s) results are negative, management will determine a 
return-to-work date after the appropriate “COVID-19 Questionnaire Form” has been 
completed 
11. Employees on a Quarantine Sick Leave can only return to work after being cleared by 
management and after the appropriate “COVID-19 Questionnaire Form” has been completed 
12. After a return-to-work date has been established, management will notify the employee(s) 
department managers 
13. Positive COVID-19 test results notifications will be managed in accordance with the current 
Safety and Sanitization guidelines. The General Manager is tasked with notifying the 
restaurant’s leadership of a positive test result. 

 
 

 
 

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Employee COVID-19 Self Reporting Questionnaire 

EMPLOYEE COVID-19 SELF REPORTING QUESTIONNAIRE 
 
Today’s Date: 
Employee Name: Department: 
Address: Phone Number: 

TRAVEL/EXPOSURE INFORMATION​ (PLEASE INCLUDE CITY, STATE OR COUNTRY) 

 
From:_______________________To:_____________________Location:____________________ 
From:_______________________To:_____________________Location:____________________ 
From:_______________________To:_____________________Location:____________________ 
 
1. If traveled, were you screened at an airport or point of entry to the US? __Y __N 
2. If YES, were you provided with any type of documentation? __Y __N 
3. While traveling, did you come in contact with anyone who displayed symptoms of COVID-19? __Y __N 
4. Have you been in close contact, or exposed to a person who has developed signed or symptoms compatible with 
COVID-19? __Y __N 
5. Do you suspect you might have been exposed to COVID-19? __Y __N 
 
If Y
​ ES​, please elaborate (including dates): 
 

 
 
 
 
 
6. Have you experienced, or are currently experiencing any of the following symptoms? 
○ Measured fever 
○ Cough 
○ Shortness of breath or difficulty breathing 
○ Muscle pain 
○ Sore throat 
○ Headache 
○ New loss of taste or smell 
○ Repeated shaking with chills 
○ Other (Indicate below) 
 

 
 
 
 

FOR MANAGEMENT USE ONLY: 

 
__ FIRST REQUEST __ FOLLOW UP REQUEST RETURN TO WORK DATE (IF APPLICABLE) _____________________ 
PUT ON LEAVE __Y / __N SUPERVISOR NOTIFIED ON __________________ 
PAID LEAVE __Y / __N SUPERVISOR NOTIFIED ON __________________ 
 
Employee Signature _____________________________ Date __________________________ 
 
Manager Signature ______________________________ Date__________________________ 

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Employee Health & Sanitization Guideline 

Agreement 
Reporting: Symptoms of Illness  
 
I agree to report to the manager when I have:  

1. Cough 
2. Shortness of breath or difficulty breathing  
3. Fever 
4. Chills  
5. Muscle pain  
6. Sore throat 
7. New loss of taste or smell 

Reporting: Diagnosed Illnesses  

I agree to report to the manager when I have:  

1. Consulted my physician and have been directed to obtain a COVID-19 screening 

2. Have completed a COVID-19 screening and the results are positive 
3. Been exposed to a COVID-19 positive individual and my physician recommends 14 day quarantine 

Reporting: Exposure of Illness 

I agree to report to the manager when I have been exposed to any of the illnesses listed above through: 

1. A household member with COVID-19  

2. A household member attending or working in a setting and was exposed to positive cases of COVID-19 

Exclusion and Restriction from Work  

If you have any of the symptoms or illnesses listed above, you may be excluded* or restricted* from work. *If you 
are excluded/restricted from work you are not allowed to come to work. 

Returning to Work  
If you are excluded from work for having COVID-19, you will not be able to return to work until more than 14 
days have passed or you have a physician's authorization that you are no longer a risk to the public or your 
co-workers or your co-workers and management approval is granted.  

Agreement  
I understand that I must:  

1. Report when I have or have been exposed to any of the symptoms of COVID-19 listed above; and 
2. Comply with work restrictions and/or exclusions that are given to me 

I understand that if I do not comply with this agreement, it may put my job at risk.  

Employee Name (please print) __________________________________________ 

Signature of Employee ___________________________ Date _________________ 

Manager Name (please print) ___________________________________________ 

Signature of Manager ___________________________ Date _________________ 

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