SAFETY SEAL CERTIFICATION CHECKLIST

Control No.:_____________________
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

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
5 Availability of isolation area for identified symptomatic employees
6 BHERTs
Availabilityand other COVID-19
of handwashing Emergency
stations hotlines
with soap, are placed
sanitizers in conspicious
and hand area. or supplies for employees
drying equipment
7 and clients/visitors in strategic location in the establishment
Installed physical barriers in enclosed areas to 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 COVID-19.
Conducts 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
CATION CHECKLIST
Date: _________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
__________Contact Details:_________________________________

is provided:

YES NO N/A

se specify other contact tracing tool. (_________________________)

ployees, clients and visitors

placed for registration of employees and clients.

area. or supplies for employees

uipment
cking off chairs, markers, stickers
ncing and ensuring the compliances
nt where
port peopleand
to Prevent gather(e.g. queue)
COntrol the
ection Prevention and Control Measure
lishment in compliance to the Cleaning
e World Health Organization.
shields especially in enclosed places.
te the conduct thereof; and c.) monitor
kused
policies.
facemasks and other infectious
 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. - StaySafe QR Code,
Please specify - If implementing own CT app, IA will
other contact tracing tool. (_________________________) verify 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 - Photo of the entrance with thermal
assess 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 - Photo the conspicious area with
conspicious area. COVID19 Emergency Hotlines
6 Availability of handwashing stations with soap, sanitizers and hand - Photo of handwashing stations/
drying equipment or supplies for employees and clients/visitors in sanitizers used by the Office
7 strategic physical
Installed location in the establishment
barriers in enclosed areas to maintain social - Photo Office Setup with physical
distancing(blocking off chairs, markers, stickers on the floor for spacing) barriers, markers or floor stickers to
help maintain social distancing

8 Availability of personnel-in-charge for monitoring and maintaining social Err:509

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

10 Compliance to the disinfection protocol in accordance with DOH - Memo re Conduct of Regular
Department Memorandum No. 2020-157 and 0157-A or the "Guidelines Disinfection/ Disinfection Protocol
on Cleaning and Disinfection in Various Settings as an Infection - Sample photo of office disinfection
Prevention and Control Measure 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 - Memo for Employees
face 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 safety officer/s
community-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 - Photo of the disposal facility/
disposal of used facemasks and other infectious wastes. mechnism 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