Section 1 of 4
COVID-19 Outbreak Management Tier 1 Checklist for Workplaces (Other- Pharmacy)
see COVID-19 Public Health Action Checklist for Workplaces on Business Continuity Plans. This form will also notify your local public health team
Date form submitted
Date form submitted
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e-mail address
e-mail address
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address of the affected setting
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Contact details
Contact details
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Name: Position: 'Phone Number:
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Details of Staff
Details of Staff
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Total number of staff, Number of staff in at one time
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Size and Layout of Workplace
Size and Layout of Workplace
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Including number of rooms, workspace areas 2m apart, number floors, sharing with different businesses, details of toilet/bathroom facilities, communal areas, details of handwashing facilities, etc
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Section 2 of 4
Details of the current confirmed case
When was the case symptomatic? (or in the absence of symptoms, when was the test taken?)
When was the case symptomatic? (or in the absence of symptoms, when was the test taken?)
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What is the infectious period (2 days prior to 10 days after the onset of symptoms/positive test date)?
What is the infectious period (2 days prior to 10 days after the onset of symptoms/positive test date)?
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Did the case attend at the setting during the infectious period?
Did the case attend at the setting during the infectious period?
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Yes
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No
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If so, what days did the case attend at the setting during the infectious period?
If so, what days did the case attend at the setting during the infectious period?
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Please describe activities of case in the setting, including locations of where the case has been in the setting
Please describe activities of case in the setting, including locations of where the case has been in the setting
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Contact tracing
Contact tracing
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Did the case have any contact with anyone else whilst infectious? i.e. Face to face contact with a case for any length of time, within 1m, including being coughed on, a face to face conversation, unprotected physical contact (skin to skin) or travel in a small vehicle with a case. This includes exposure within 1 metre for 1 minute or longer and extended close contact (between 1 and 2 metres for more than 15 minutes) with a case.
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Section 3 of 4
Multiple cases?
If more than one confirmed case or where there are a number of symptomatic/self-isolating cases, please complete this section on assessing possible outbreaks
Number of suspected and confirmed cases
Number of suspected and confirmed cases
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Date of onset in first case
Date of onset in first case
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Date of onset in most recent case
Date of onset in most recent case
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Last day in the work setting for cases
Last day in the work setting for cases
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Nature of the symptoms for each case
Nature of the symptoms for each case
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Fever, cough, change in sense of smell/taste, other symptoms
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Any specific areas affected in the workplace?
Any specific areas affected in the workplace?
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Any tests already done?
Any tests already done?
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Obtain case details to f/u results
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Any further testing arranged?
Any further testing arranged?
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Any cases required admission to hospital?
Any cases required admission to hospital?
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Number of deaths
Number of deaths
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Number of staff currently in isolation/shielding
Number of staff currently in isolation/shielding
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Past Outbreaks?
Past Outbreaks?
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Number of past outbreaks, dates (start date), number of staff affected
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Section 4 of 4
Meetings and Workspace – Identifying potential contact risks
What social distancing measure are in place? Are they being followed?
Do employees attend any ‘in person’ meetings?
Do employees attend any ‘in person’ meetings?
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Yes
2.
No
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Workstations/area - hot desking, 2m apart
Workstations/area - hot desking, 2m apart
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Actioned
Not actioned
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add "Other"
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Is PPE being worn? (need for PPE dependent on type of work).
Is PPE being worn? (need for PPE dependent on type of work).
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Yes
2.
No
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Are there communal areas?
Are there communal areas?
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(kitchen, canteen, smoking areas etc)
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Yes
2.
No
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Are there workers who share transport to/from work and/or share accommodation?
Are there workers who share transport to/from work and/or share accommodation?
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Yes
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No
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