COVID-19 Physical Distancing Audit Tool

Site: Name of Site Department:

Name of Department(s) Manager/contact:

Name

Audit date:

Date Audit #: Start and finish time:

____________ to ____________

Previous audits? ☐ Yes ☐ No

Auditor(s):

Names Other participants:

Names

Overall compliance %: Instructions for use:1.0 Environmental Assessment – visually located the items listed in order to mark ‘yes’ or ‘no’2.0 Behavioral Assessment - Observation = each event is an observation (i.e., when a question is asked you observe as many of those situations

as you can record in the lines provided during the 10-minute session)

Recommended follow up actions:

IMPORTANT INFORMATION FOR AUDITORS

June 23, 2020 COVID-19 Physical Distancing Audit Tool | Page 1 of 7

Yes No N/A % yes/total (yes + no)1.1 Environmental assessment - Signage1.2 Environmental assessment –Supplies/equipment1.3 Environmental assessment –layout2.1 Behavior assessment – observedTotals

COVID-19 Physical Distancing Audit Tool

1. Environmental AssessmentCompletion legend Y: Yes | N: No | N/A: Not Applicable

1.1 Environmental Assessment – Signage

Item Y N N/A Comments1.1.1 COVID-19 social distancing signage visible in

areas of congregation/shared spaceEnglishFrench

☐ ☐ ☐

1.1.2 COVID-19 stairs signage visible at entry to staircases

☐ ☐ ☐

1.1.3 COVID-19 elevator signage visible in or at elevatorsNote: smaller elevators may need to be 1 person maximum if space less than 2 metres/6 feet inside space.

☐ ☐ ☐

1.1.4 COVID-19 Test sites: Test sites signage is visible at entrances and client waiting areasEnglish English (large)French French (large)Mandarin Mandarin (large)Spanish

☐ ☐ ☐

Total

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COVID-19 Physical Distancing Audit Tool

1.2 Environmental Assessment – supplies/equipment

Item Y N N/A Comments1.2.1 Documented process in place to

clean/disinfect regularly used equipment (not including electronics)Frequency minimum: after use

☐ ☐ ☐

1.2.2 Dedicated equipment and/or supplies recommended. If shared cleaned between use

☐ ☐ ☐

1.2.3 Documented process available to clean/disinfect electronics (i.e., cell phone, IPAD, computers, printers, etc.)Frequency minimum: twice dailyNote: partial if done once daily

☐ ☐ ☐

1.2.4 Process in place to disinfect frequently used surfaces (i.e., phone, doorknobs, elevator buttons, rails, etc.)Frequency minimum: twice dailyNote: partial if done once daily

☐ ☐ ☐

1.2.5 Facility approved disinfectant available? ☐ ☐ ☐1.2.6

Hand Hygiene supplies available? ☐ ☐ ☐

Total

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COVID-19 Physical Distancing Audit Tool

1.3 Environmental Assessment – layout

Item Y N N/A Comments

1.3.1

Is the ‘maximum people’ capacity posted on all congregated meeting areas/ communal spaces (break rooms, break rooms, patient/resident dining areas, meeting rooms, etc.)?

☐ ☐ ☐

1.3.2Is the posted ‘maximum people’ capacity a reasonable number to allow for 2 metre separation of room attendees?

☐ ☐ ☐

1.3.3

Does seating allow for 2 metre separation in room (i.e., no extra chairs beyond room capacity to maintain)?Locations include cafeterias, break rooms, patient/resident dining areas, meeting rooms, etc.).

☐ ☐ ☐

1.3.4

For areas that have wheelchair use, is 2 metre separation marked on the floor to clearly identify where it is acceptable to ‘park’ in congregated settings/ communal spaces (i.e., dining areas)?

☐ ☐ ☐

1.3.5 Is there an assigned seating has posted seating chart (where necessary)?

☐ ☐ ☐

Total

Item Observation # Y N N/A Comments

2.1.1 Is patient/resident/client Hand Hygiene observed on the unit/area? ☐ ☐ ☐

2.1.2 Is staff Hand Hygiene observed on the unit/area? ☐ ☐ ☐

2.1.3 1 ☐ ☐ ☐

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COVID-19 Physical Distancing Audit Tool

During group activities: Is the limit number of patients/residents/client

2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐6 ☐ ☐ ☐

2.1.4

Patient/resident/client group activities: Are patients/residents/ clients spaced as far from one another as possible, maintaining a minimum distance of 2 metres between them?

1 ☐ ☐ ☐2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐6 ☐ ☐ ☐

2.1.5

Staff groups of 2 or more: Are staff spaced as far from one another as possible, maintaining a minimum distance of 2 metres between them? Note: mark N/A when providing clinical care or doing an essential activity that requires close contact and extended use PPE)

1 ☐ ☐ ☐2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐

6 ☐ ☐ ☐

2.1.6

Number of hugs, handshakes, touching (outside of clinical necessary interaction) over course of the audit minimum observation = 10 minutes

1 ☐ ☐ ☐2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐6 ☐ ☐ ☐7 ☐ ☐ ☐8 ☐ ☐ ☐

Sub-total

2.1. Behavior Assessment- Observed (10 minutes)

Item Observation # Y N N/A Comments2.1.7 Is there 2 metre separation of

the people in the space right now (observation length of audit – approximately 10 minutes)?

1 ☐ ☐ ☐2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐6 ☐ ☐ ☐

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COVID-19 Physical Distancing Audit Tool

Exception: do not count clinical staff completing necessary client care

7 ☐ ☐ ☐8 ☐ ☐ ☐9 ☐ ☐ ☐

10 ☐ ☐ ☐

2.1.8

Do staff in the area know what the social distance parameters should be?

Ask: How far away should you be when you are not providing clinical care? (Answer: 2 metres/6 feet)

1 ☐ ☐ ☐2 ☐ ☐ ☐3 ☐ ☐ ☐4 ☐ ☐ ☐5 ☐ ☐ ☐6 ☐ ☐ ☐7 ☐ ☐ ☐8 ☐ ☐ ☐9 ☐ ☐ ☐

10 ☐ ☐ ☐TotalSub-Total from page 5Overall total 2.1

Item Staff Comments3.1.1 Were challenges noted with social

distancing?Examples include:

Entrances Clutter Heavy traffic (multiple

people)

1

2

3

4

5

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COVID-19 Physical Distancing Audit Tool

6

3. Social Distancing Challenges

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