SAFETY SEAL CERTIFICATION CHECKLIST

Control No.:_____________________ Date: _________________

Name of Establlishment:________________________________________________________________________________________________________
Nature of Establishment:________________________________________________________________________________________________________
Address:_____________________________________________________________________________________________________________________
Name of Person in Charge:_________________________________________________________Contact Details:_________________________________

Instruction: (✓) Check the appropriate box (Yes/No), if the following requirement is provided:

# REQUIREMENTS YES NO N/A

1
Use of StaySafe.ph or any contact tracing tool integrated with the same. Please specify other contact tracing tool. (_________________________)
2 Availability of temperature or thermal scanner(e.g. thermal gun) to assess employees, clients and visitors
3 Availability of health declaration sheet for employees and clients
4 QR Codes for StaySafe.ph and any other contract tracing tool conspiciously placed for registration of employees and clients.
5 Availability of isolation area for identified symptomatic employees
6 BHERTs
Availabilityand
of other COVID-19
handwashing Emergency
stations hotlines
with soap, are placed
sanitizers in conspicious
and hand area. or supplies for employees
drying equipment
7 and clients/visitors
Installed in strategic
physical barriers locationareas
in enclosed in thetoestablishment
maintain social distancing(blocking off chairs, markers, stickers
8 on the floorof
Availability forpersonnel-in-charge
spacing) for monitoring and maintaining social distancing and ensuring the compliances
9 of clients/visitors/employees
No. 224-21 or the Guidelinestoonhealth protocols
Ventilation and areas inand
for Workplaces thePublic
establishment
Transportwhere peopleand
to Prevent gather(e.g. queue)
COntrol the
10 Spread
or of COVID-19
the "Guidelines on Cleaning and Disinfection in Various Settings as an Infection Prevention and Control Measure
11 Against
Conducts COVID-19.
regular(at least twice a week) cleaning and disinfection in the establishment in compliance to the Cleaning
12 and Disinfection of Environmental Surfaces in the Context of COVID-19 by the World Health Organization.
13 Personnel, employees, clients and visitors always wear facemasks and face shields especially in enclosed places.
14 Established referraland
facilities for severe system for care,
critical medical
b.) and psychosocial
undertake contactservices.
tracing or coordinate the conduct thereof; and c.) monitor
15 status of employees
Availability of storagequarantined or isolated;
facility for proper and d.)
collection, implement
treatment, andreturn to work
disposal policies.
of used facemasks and other infectious
16 wastes.
17 Business Permit / Mayor's Permit
 Republic of the Philippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, West Triangle, Quezon City
http://www.dilg.gov.ph
SAFETY SEAL CERTIFICATION CHECKLIST
(DILG as Issuing Officer)
Control No.:_____________________ Date: _________________
Name of Government Agency/ Office:________________________________________________________________________________________________________
Name of Government Establlishment/ Department/ Office/ Unit :______________________________________________________________________________________________
Address:_____________________________________________________________________________________________________________________
Name of Person in Charge:_________________________________________________________Contact Details:_________________________________
Instruction: (✓) Check the appropriate box (Yes/No), if the following requirement is provided:
# REQUIREMENTS MOVs to be Produced/ Uploaded YES NO N/A Reason why N/A
1 Use of StaySafe.ph or any contact tracing tool integrated with the same. Please - StaySafe QR Code,
specify - If implementing own CT app, IA will verify
other contact tracing tool. (_________________________) DILG CO if it is integrated with StaySafe.
- Use of manual CT may be considered at
the moment.

2 Availability of temperature or thermal scanner (e.g. thermal gun) to assess - Photo of the entrance with thermal
employees, clients and visitors scanner/ temperature checking
3 Availability of health declaration sheet for employees and clients NA if there is an online CT.
If no CT, a photo of the form required to
be filled up by employees and clients.

4 Availability of isolation area for identified symptomatic employees - Photo of the designated are
- Internal Memo designating the same (if
any)
5 BHERTs and other COVID-19 Emergency hotlines are placed in conspicious - Photo the conspicious area with
area. COVID19 Emergency Hotlines
6 Availability of handwashing stations with soap, sanitizers and hand drying - Photo of handwashing stations/
equipment or supplies for employees and clients/visitors in strategic location in sanitizers used by the Office
7 the establishment
Installed physical barriers in enclosed areas to maintain social - Photo Office Setup with physical barriers,
distancing(blocking off chairs, markers, stickers on the floor for spacing) markers or floor stickers to help maintain
social distancing

8 Availability of personnel-in-charge for monitoring and maintaining social - Memo - Designation of Personnel-in-
distancing and ensuring the compliances of clients/visitors/employees to health Charge of monitoring and maintaining
protocols and areas in the establishment where people gather(e.g. queue) social distancing and of ensuring the
compliances of clients/ vistors/ employees
to health protocols

9 Availability of windows for adequate air exchange in enclosed(indoor) areas as - Photo of air purifier in the Office (if
cited in DOLE Department Order No. 224-21 or the Guidelines on Ventilation for available)
Workplaces and Public Transport to Prevent and Control the Spread of COVID- - Or, Photo of Proper Air Ventilation of the
19 Office

10 Compliance to the disinfection protocol in accordance with DOH Department - Memo re Conduct of Regular
Memorandum No. 2020-157 and 0157-A or the "Guidelines on Cleaning and Disinfection/ Disinfection Protocol
Disinfection in Various Settings as an Infection Prevention and Control Measure - Sample photo of office disinfection
Against COVID-19.

Conducts regular (at least twice a week) cleaning and disinfection in the
establishment in compliance to the Cleaning and Disinfection of Environmental
Surfaces in the Context of COVID-19 by the World Health Organization.

11 Personnel, employees, clients and visitors always wear facemasks and face - Memo for Employees
shields especially in enclosed places. - Photo of signages re reminder to wear
facemasks and faceshields

12 Established referral system for medical and psychosocial services. - Copy of MOA/ Implementing Procedures
re referral system for medical and
psychosocial services
13 Availability of designated Safety Officer with the following functions - Memo specifying the name/s of the
a.) coordinate with the appropriate bodies for support and referral to community- safety officer/s
based isolation facilities for confirmed cases with mild symptoms, and to health
facilities for severe and critical care,
b.) undertake contact tracing or coordinate the conduct thereof; and
c.) monitor status of employees quarantined or isolated; and
d.) implement return to work policies.

14 Availability of storage facility for proper collection, treatment, and disposal of - Photo of the disposal facility/ mechnism
used facemasks and other infectious wastes. for infectious waste

I hereby certify that the facts stated herein are true and correct of my own personal knowledge and any misrepresentation subjects me to criminal or administrative liability.

Name and Signature of Person in Charge / Date

FOR ONSITE VALIDATION/ INSPECTION

DEFECTS / DEFICIENCIES NOTED DURING INSPECTION:

RECOMMENDATIONS:

Name and Signature of Safety Seal Inspector / Date