CHECKLIST ON COMPLIANCE WITH SAFETY AND HEALTH MEASURES TO

PREVENT AND CONTROL COVID-19 TRANSMISSION

Name of Establishment: Kind of Business/Economic Activity/Principal Product:

Name of Owner/President/Manager: Contact No.:

Address:
Email Address:
Head Office Branch
Kind of Ownership Total number of workers:
Sole Proprietorship Partnership Age Group Female Male Total
Corporation Cooperative below 15
No. of Shifts: ___
Shift time 15-19 yrs
No. of Workers 20-59 yrs

Employment Status Female Male Total

No. of Regular: No. of Managerial:
No. of Probationary: No. of Supervisory:
No. of Fixed-Term: No. of Rank and File:
No. of Casual: TOTAL:
No. of Regular-Seasonal:
No. of Contractors' employees
deployed:
Type of Workplace:
Low Risk Medium Risk High Risk
Name of Employer's Representative: Name of Employees' Representative:

COMPLYING REQUIRED CORRECTION

COMPLIANCE INDICATOR Workers Schedule of
YES NO N/A Remarks
Involved Correction
PREVENTIVE/CONTROL MEASURES BEFORE ENTRY TO BUILDINGS OR WORKPLACES
Signages on COVID Safety Measures posted in the premises
Wearing of face masks at all times
Daily accomplishment of Health Symptoms Questionnaire
Accomplished Health Symptoms Questionnaire submitted to HR/Clinic
personnel
Temperatures checked for both workers and visitors
Spraying of alcohol/sanitizers on both hands done
Disinfectant foot baths at the entrance provided, if practicable
Isolation areas provided
a. Well-ventilated
b. Frequently disinfected
c. OSH personnel to handle COVID-19 symptomatic workers present
d. Appropriate medical grade PPEs for OSH personnel provided
e. Contact numbers of nearest DOH Facility/BHERT posted at
conspicuous
f. Protocolsplaces
for referral and transporting workers with COVID-19
symptoms established
Equipment or vehicle entering the premises disinfected, if applicable
Social or physical distancing of at least 1 meter observed
PREVENTIVE/CONTROL MEASURES INSIDE THE WORKPLACE
Company Safety and Health Program in compliance to DTI-DOLE Interim
Guidelines formulated
Company Commitment to comply with OSH requirements and Updated OSH
Program to include Covid Control Plan/Program
Signages on COVID Safety Measures posted in the premises
Common areas and frequently handled objects disinfected at an interval of
not less than 2 hours
Frequent handwashing observed
Clean water and soap in all washrooms and toilets provided
Sanitizers in all areas where workers pass provided
Physical distancing of at least 1 meter radius of space between each worker
a. Strategic work shift implemented
b. Signages for "one way direction" in walkways established
c. Directional signages posted for one-way out in walkways, elevators
and on stairs
d. Transparent barriers between office tables and open work spaces
provided, if applicable
e. Use of shared tools and equipment done one at a time
f. Use of phones, email and other virtual platforms for office work and
meetings encouraged
Disinfection done every after use of tools and equipment shared
Social distancing when eating in communal spaces observed
Workers encouraged to bring their own packed lunch and snacks in their
own work area
Nutritious meals available in the canteen, if applicable
Vitamins provided, if capable
Proper waste disposal
MINIMIZING CONTACT RATE
Feasible alternative work arrangements implemented
Meetings needing physical presence kept to a minimum number of
participants and of short duration
Video-conferencing for lengthy discussions or meetings encouraged
Number of people in enclosed spaces (rooms, stores, halls, elevators)
limited to observe at least one (1) meter physical distancing
For establishments with two (2) accessible stairways, one stairway is used
exclusively for going up and the other for going down with directional signs
posted
Appropriate PPEs (in addition to face masks) provided to cleaners by the
employer at PPEs
Appropriate no cost to them
(e.g. N95, surgical masks or reusable masks, gowns,
gloves) are properly worn by the workers while at work
Proper disposal of PPEs done after use
Work from Home Arrangement for vulnerable workers implemented
(With Co-Morbidities, younger than 20 years; 60 years and older, Pregnant, and
Immunocompromised)

Safety officers to ensure physical distancing and observance of minimum

health protocols assigned
Online system for clients needing assistance practiced / encouraged, if
applicable
IEC (Information, Education and Communication) STRATEGIES
OSH personnel are properly informed about the COVID 19 Interim Guidelines

Latest updates on COVID 19 and emergency contact details are widely

disseminated
Physical and Mental resiliency activities undertaken
DOLE Hotline (Tel. No. 1349) posted
COST FOR IMPLEMENTING COVID PREVENTION PROGRAM/PLAN
Cost for implementation of COVID prevention and control program is alloted
from the establishment's budget for operational expenses
REPORTING AND REFERRAL SYSTEM
Monthly report using the DOLE-WAIR COVID Form submitted to DOLE
Regional Office
Probable/suspect/confirmed COVID-19 case reported within 24-hours
Established referral system for workers needing assistance with mental
health concerns

Monitoring Team:

____________________________________________________ ____________________________________________________
Name and Signature of DOLE Representative Name and Signature of DTI Representative

Received by:

____________________________________________________ ____________________________________________________
Name and Signature of Employer's Representative Name and Signature of Employee's Representative

Date Monitored: _______________________________________________

 CHECKLIST ON COMPLIANCE WITH SAFETY AND HEALTH MEASURES TO
PREVENT AND CONTROL COVID-19 TRANSMISSION

Name of Establishment: Kind of Business/Economic Activity/Principal Product: Furniture

Name of Owner/President/Manager:
Address:

Head Office X Branch

Kind of Ownership Total number of workers:4
Sole Proprietorship Partnership Age Group Female Male Total
X Corporation Cooperative below 15
No. of Shifts: _1_
Shift time 15-19 yrs
No. of Workers 20-59 yrs 5 5
10:00 am - 6:00 pm 2

Employment Status Female Male Total

No. of Regular: 5 5 No. of Managerial: 1
No. of Probationary: 0 0 No. of Supervisory:2
No. of Fixed-Term: 0 0 No. of Rank and File:2
No. of Casual: 0 0 TOTAL:5
No. of Regular-Seasonal: 0 0
No. of Contractors' employees
deployed: 0 0
Type of Workplace:
X Low Risk Medium Risk High Risk
Name of Employer's Representative: Hilton Cedrick L. Cutero Name of Employees' Representative: Hilton Cedrick L. Cutero

COMPLYING REQUIRED CORRECTION

COMPLIANCE INDICATOR Workers Schedule of
YES NO N/A Remarks
Involved Correction
PREVENTIVE/CONTROL MEASURES BEFORE ENTRY TO BUILDINGS OR WORKPLACES
Signages on COVID Safety Measures posted in the premises X
Wearing of face masks at all times X
Daily accomplishment of Health Symptoms Questionnaire X
Accomplished Health Symptoms Questionnaire submitted to HR/Clinic
personnel X
Temperatures checked for both workers and visitors X
Spraying of alcohol/sanitizers on both hands done X
Disinfectant foot baths at the entrance provided, if practicable X
Isolation areas provided X
a. Well-ventilated X
b. Frequently disinfected X
c. OSH personnel to handle COVID-19 symptomatic workers present X
d. Appropriate medical grade PPEs for OSH personnel provided X
e. Contact numbers of nearest DOH Facility/BHERT posted at X
conspicuous
f. Protocolsplaces
for referral and transporting workers with COVID-19
symptoms established X
Equipment or vehicle entering the premises disinfected, if applicable X
Social or physical distancing of at least 1 meter observed X
PREVENTIVE/CONTROL MEASURES INSIDE THE WORKPLACE
Company Safety and Health Program in compliance to DTI-DOLE Interim
Guidelines formulated X
Company Commitment to comply with OSH requirements and Updated OSH
Program to include Covid Control Plan/Program X
Signages on COVID Safety Measures posted in the premises X
Common areas and frequently handled objects disinfected at an interval of
not less than 2 hours X
Frequent handwashing observed X
Clean water and soap in all washrooms and toilets provided X
Sanitizers in all areas where workers pass provided X
Physical distancing of at least 1 meter radius of space between each worker X
a. Strategic work shift implemented X
b. Signages for "one way direction" in walkways established X
c. Directional signages posted for one-way out in walkways, elevators
and on stairs X
d. Transparent barriers between office tables and open work spaces
provided, if applicable X
e. Use of shared tools and equipment done one at a time X
f. Use of phones, email and other virtual platforms for office work and
meetings encouraged X
Disinfection done every after use of tools and equipment shared X
Social distancing when eating in communal spaces observed X
Workers encouraged to bring their own packed lunch and snacks in their
own work area X
Nutritious meals available in the canteen, if applicable X
Vitamins provided, if capable X
Proper waste disposal X
MINIMIZING CONTACT RATE
Feasible alternative work arrangements implemented X
Meetings needing physical presence kept to a minimum number of
participants and of short duration X X
Video-conferencing for lengthy discussions or meetings encouraged X X
Number of people in enclosed spaces (rooms, stores, halls, elevators)
limited to observe at least one (1) meter physical distancing X
For establishments with two (2) accessible stairways, one stairway is used
exclusively for going up and the other for going down with directional signs
posted
X
Appropriate PPEs (in addition to face masks) provided to cleaners by the X
employer
Appropriateat PPEs
no cost to them
(e.g. N95, surgical masks or reusable masks, gowns,
gloves) are properly worn by the workers while at work X
Proper disposal of PPEs done after use X
Work from Home Arrangement for vulnerable workers implemented
(With Co-Morbidities, younger than 20 years; 60 years and older, Pregnant, and
Immunocompromised)
X
Safety officers to ensure physical distancing and observance of minimum
health protocols assigned X
Online system for clients needing assistance practiced / encouraged, if
applicable X
IEC (Information, Education and Communication) STRATEGIES
OSH personnel are properly informed about the COVID 19 Interim Guidelines
X
Latest updates on COVID 19 and emergency contact details are widely
disseminated X
Physical and Mental resiliency activities undertaken X
DOLE Hotline (Tel. No. 1349) posted X
COST FOR IMPLEMENTING COVID PREVENTION PROGRAM/PLAN
Cost for implementation of COVID prevention and control program is alloted
from the establishment's budget for operational expenses X
REPORTING AND REFERRAL SYSTEM
Monthly report using the DOLE-WAIR COVID Form submitted to DOLE
Regional Office X
Probable/suspect/confirmed COVID-19 case reported within 24-hours X
Established referral system for workers needing assistance with mental
health concerns X

Submission of any document or legal writing before this Office to determine violations or aid in the enforcement of existing labor laws, wage order, rules and regulations shall include the
assurance by the employer that the same is true and correct on its face and is binding upon him/her. Any person who makes any statement, report or record knowing such statement, report
or record to be false in any material respect shall be penalized in accordance with law.

Monitoring Team:

____________________________________________________ ____________________________________________________
Name and Signature of DOLE Representative Name and Signature of DTI Representative

Received by:

Name and Signature of Employer's Representative Name and Signature of Employee's Representative
Date Monitored: _______________________________________________