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APPENDIX A
EMPLOYER / EMPLOYEE
COVID-19 POLICY AND PROCEDURES
For “Phase I” Returning Employees
From: ___________________________________ and its affliates and associated entities (“Company”) To: _______________________________________________________________________
Date: ___________________________________ Re: COVID-19 policy
Dear Employee: Thank you for being a part of the “Phase I” group of employees returning to our offces after most of us began working from home as per the directive of [NAME] and reinforced by law upon the orders of New York Governor Andrew Cuomo, in response to the COVID-19 pandemic. We have taken this time to educate ourselves about COVID-19, and to develop policies and procedures, based on the latest Centers for Disease Control (CDC) guidelines, for a safe and healthy workplace, as well as procuring the necessary Personal Protective Equipment (PPE) to implement these new guidelines. As always, your safety, and the safety of your fellow employees, is of the utmost importance. Phase I will be the frst part of a multi-phase plan to resume work at our offce headquarters in support of our Company operations, utilizing these policies and procedures to ensure the safety of our employees and labor force during the continually evolving circumstances of the COVID-19 pandemic. As a Phase I employee who will be returning to the offce on [DATE], we must require that you, as a condition of re-entering the premises, provide certain information as requested below and agree in writing to the following:
1. CONTACT INFORMATION
Name: Current Address: Cell No.: Email: Home No.: Emergency Contact Name: Emergency Contact Cell No.:
INTIAL YOUR CONSENT _______
2. HEALTH CERTIFICATIONS
In the event that I, or anyone in my household, or anyone that I have come into close contact with (less than 6 feet) in the absence of appropriate PPE and / or adherence to CDC guidelines, has had a fever (higher than 100°F / 38°C) and / or symptoms consistent with COVID-19 [including, but not limited to: a dry cough that has continued for more than one day; diffculty breathing; unusual fatigue; persistent pain of pressure in the chest; bluish lips, face or extremities; confusion, inability to awaken; loss of consciousness; or any other symptom set forth by the CDC (www.cdc.gov), I certify that: a. I have had no fever for at least 72 hours (that is three full days of no fever without the use of medicine that reduces fevers); AND b. Other symptoms have improved (for example, cough or shortness of breath have improved); AND c. At least 7 days have passed since any such symptoms (if any) frst appeared; AND d. If I’ve had no symptoms, at least 14 days have passed since my exposure to any such individual who has presented with these symptoms.
In the event that I have been diagnosed with COVID-19, I certify that: a. I no longer have a fever (without medicine that reduces fevers); AND b. Other symptoms have improved (for example, when cough or shortness of breath have improved); AND c. I have received two negative tests in a row, at least 24 hours apart; OR d. If testing is not currently available: i. at least 7 days have passed since any such symptoms frst appeared; AND ii. I have had no fever without the use of fever-reducing medicine for at least 72 hours;, AND iii. my other symptoms have improved (for those who have had no symptoms, at least 7 days have passed since the date of their frst positive COVID-19 diagnostic test and they have had no subsequent illness and they remain asymptomatic).
INTIAL YOUR CONSENT _______
3. COVENANT AS TO HEALTH STATUS AND CERTIFICATIONS I certify as follows-
a. In the event there is any change in any of the information contained in No. 1 (Contact Information) and / or No. 2 (Health Certifcation), I will promptly advise [NAME], [TITLE], in writing via email at [EMAIL] of such change or changes. If you do not have access to email, you may also leave a message at [# NUMBER]). b. In the event of any change in No. 2 (Health Certifcation), I agree that I will not come to work, or go to the site, and will instead stay home. c. If you have a fever (100°F / 38°C or above), are feeling unwell or experiencing fu-like symptoms, or have been in contact with a person(s) known to be infected or under quarantine, please do not come to the offce or job site. Advise the Company, and seek medical attention as appropriate. d. If any time during the work day my condition changes, after I have arrived at the offce or at a job site, I agree to immediately leave and go home after notifying my supervisor, who will notify Company/[NAME], on my behalf. e. In accordance with the Families First Coronavirus Response Act, signed into law on March 18, 2020, and any other or subsequent actions of the Federal, State or Local Government, I agree
to keep Company/[NAME] current of any testing for COVID-19 that I may schedule and provide Company / HR with the results of those tests. I agree to cooperate with the Company and sign any forms that may be needed in that regard.
INTIAL YOUR CONSENT _______
4. COMPANY EFFORTS
a. No visitor access will be granted to the work premises without prior approval, and only when absolutely necessary. b. Ensure that the work premises will be kept clean and sanitized with hospital grade disinfectants on a daily basis. c. Provide signs with important health information and hand sanitizer dispensers will be available throughout the facility. d. The availability of remote access, software and applications, such as video and / or telephone conferencing, electronic document signing and other electronic means and methods, and that it will be utilized to the greatest extent practicable in order to minimize physical contact between different persons during this time.
INTIAL YOUR CONSENT _______
5. CONSENT / ASSUMPTION OF RISK
a. Company will endeavor to provide employee, whether on-site or at the offce, with appropriate safety PPE. However, Company cannot assure employee that the PPE to be provided will be effective, of suffcient quality, or available in suffcient quantities. b. As such, employee acknowledges and agrees that he, she, they will go to work or the job site at their own risk. c. Employee further states and acknowledges that contraction of the virus could happen at locations other than on-site or at the Company offce(s). Employee agrees to take measures to protect himself / herself / themselves, including but not limited to social distancing, hand washing, avoidance of facial touching, etc., and as otherwise recommended by Governmental health professionals. d. As an additional safety measure, essential employees still coming to the offce or job site should monitor their temperature daily. You agree to take your temperature in the morning and evening to ensure you do not have a fever (fever 100°F / 38°C or above) before coming to work. We are asking employees to take responsibility to self-monitor to protect themselves and the health and safety of their colleagues. e. All employees may be required to submit to temperature testing or such other measures or testing as Company reasonably determines to be necessary. Any employee who has a fever of higher than 100°F / 38°C or shows visual symptoms consistent with CDC guidelines, may, in the sole discretion of the Company supervisor, be asked to go home and may not be permitted to enter the work site or
Company offce. You consent to this testing and to this protocol and procedure.
INTIAL YOUR CONSENT _______
6. CONFIDENTIALITY / MISCELLANEOUS
a. This form / agreement, and all information provided to Company and its HR Department shall remain strictly confdential except in a circumstance required by law, legal process or to enforce or construe the provisions of this agreement. b. This form / agreement shall survive termination of employment, bankruptcy of the Company, death, disability, or further Governmental order or directive. c. This form / agreement is binding upon the employee and his / her / their representatives, executors, administrators, assigns. d. This form / agreement is binding upon the Company, its affliates, its associated entities, and its / their successors and / or assigns.
INTIAL YOUR CONSENT _______
I HAVE READ THE ABOVE AND AGREE TO BE BOUND TO THE TERMS, CONDITIONS, AND REPRESENTATIONS CONTAINED THEREIN INCLUDING MY OBLIGATION TO NOTIFY THE COMPANY OF ANY CHANGES TO THE INFORMATION CONTAINED HEREIN. I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUTHFUL, ACCURATE AND COMPLETE KNOWING THE COMPANY WILL BE REPLYING UPON THIS DISCLOSURE.
