Sample Hazard Assessment
OSHA released on June 10 the COVID-19 Healthcare Emergency Temporary Standard (ETS). It requires offices
subject to the ETS to conduct a facility-specific hazard assessment for any COVID-19-related hazards and develop
a mitigation plan. Non-managerial employees must be involved in this process. Use this document as an exampleof a sample hazard assessment and customize to meet your facility’s needs.

COVID-19 Hazard Assessment
Company/Organization 																								Address 																									Prepared by 																 Date 									Consideration

Risk LevelLowMedium
Job-specific analysis

Which jobs in your facility have thegreatest risk of exposure to COVID-19?

What procedures/activities in your facility
place employees at risk for contracting COVID-19?

High

Plan to address or mitigate any issues

Risk Level

Consideration

Low

Medium

High

Employee/patient considerations
What is the risk level based on infection
and vaccination rates in your area?

Low riskMedium risk

High risk

Are all staff vaccinated?

All staff are vaccinatedSome staff are vaccinatedNo staff are vaccinated

Can employees perform teleworkor otherwise work remotely?

All employees may telework

Some employees
may telework

No employees may telework

Are patients, visitors and staff subject tohealth screenings upon entry to the practice?

All patients, visitorsand staff are subject
to screening

Only unvaccinated patientsand visitors are subject
to screening

No screening is performed

Are masks required to be utilized
by all individuals in the practice?

All patients, visitorsand staff must wear masks

Only unvaccinatedpatients, visitors and staff
are required to wear masks

No masks are required

Are employees required
to share any equipment?

Equipment is individual toeach employee or sanitized
between uses

Some equipment isindividual to each employee
while others are shared

Employees share
all equipment

Is there a process for employees toreport work hazards related to COVID-19?

A formal process has
been established andcommunicated to theemployees

A procedure is inplace but not formalized.

No process is in place

Plan to address or mitigate any issues

Risk Level

Consideration

LowMediumHigh

Building considerations
Are airflow mitigations in place (e.g., HEPA filters,
exhaust airflow checked, outside air circulation provided)?

Yes

Some mitigations in place

No mitigations in place

Is a MERV-13 filter being used in the HVAC system?

Yes

No, but highest filter
compatible with HVAC
is being used

Low-rate filter being used

Are physical barriers present?

Yes

Some barriers

No barriers

Are administrative controls such as foot-traffic
control being used to minimize employee exposure?

Foot-traffic administrative
controls are being utilized
in all spaces

Some foot traffic
administrative
controls are in place

No foot traffic
administrative
controls are utilized

Is social distancing utilized in all spaces?

Six-foot requirements
are in place and marked
accordingly in facility

Some social
distancing utilized

No socialdistancing utilized

Plan to address or mitigate any issues

Risk Level

Consideration

Low

MediumHigh

Plan to address or mitigate any issues

Building considerations (continued)
Are written cleaning and sanitation
policies in place to address COVID-19?

All spaces and surfaces
are accounted for in theCOVID-19 cleaning policy

Yes, some spaces andsurfaces are accounted
for in the COVID-19
cleaning policy

No written policy exists

View OSHA’s COVID-19 ETS for additional information.
The information provided in this document is intended for educational purposes only. In no event shall AAOMS be liable for any decision made or action taken or not taken byanyone in reliance on the information contained in this resource. For practice, financial, accounting, legal or other professional advice, professional advisers should be consulted.

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