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

(_______________ as Issuing Officer)
Control No. Date
Name of Government Agency/ Office
Name of Government Establlishment/ Department/ Office/ Unit
Nature of Government Establlishment/ Department/ Office/ Unit
Address
Name of Person in Charge Contact No.

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 verify DILG CO if it
other contact tracing tool. (_________________________) 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 scanner/
assess employees, clients and visitors 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 COVID19 Emergency
conspicious area. Hotlines
6 Availability of handwashing stations with soap, sanitizers and hand drying - Photo of handwashing stations/ sanitizers used by the
equipment or supplies for employees and clients/visitors in strategic Office
location in the establishment
7 Installed physical barriers in enclosed areas to maintain social - Photo Office Setup with physical barriers, markers or
distancing(blocking off chairs, markers, stickers on the floor for spacing) floor stickers to help maintain social distancing
8 Availability of personnel-in-charge for monitoring and maintaining social - Memo - Designation of Personnel-in-Charge of
distancing and ensuring the compliances of clients/visitors/employees to monitoring and maintaining social distancing and of
health protocols and areas in the establishment where people gather(e.g. ensuring the compliances of clients/ vistors/ employees to
queue) health protocols
9 Availability of windows for adequate air exchange in enclosed(indoor) - Photo of air purifier in the Office (if available)
10 areas as cited
Compliance to in
theDOLE Department
disinfection Order
protocol No. 224-21 with
in accordance or the Guidelines
DOH -- Or,
MemoPhoto of ProperofAir
re Conduct Ventilation
Regular of the Office
Disinfection/ Disinfection
on Ventilation
Department for Workplaces
Memorandum No.and Public Transport
2020-157 and 0157-Ato or
Prevent and
the "Guidelines Protocol
Control
on the Spread
Cleaning of COVID-19
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
12 face shields referral
Established especially in enclosed
system places.
for medical and psychosocial services. -- Photo ofMOA/
Copy of signages re reminder
Implementing to wear facemasks
Procedures re referraland
faceshields
system for medical and psychosocial services
13 Availability of designated Safety Officer with the following functions - Memo specifying the name/s of the safety officer/s
a.) coordinate with the appropriate bodies for support and referral to
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/ mechnism for infectious
disposal of used facemasks and Iother infectious wastes. waste
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

 SAFETY SEAL CERTIFICATION CHECKLIST
(_______________ as Issuing Officer)
Control No. Date
Name of Establishment
Nature of Establishment
Address
Name of Person in Charge Contact No.

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 Valid Business Permit/Mayor's Permit - Presence of a valid Business/Mayor's Permit
2 Use of StaySafe.ph or any contact tracing tool integrated - StaySafe QR Code,
with the same. Please specify - If implementing own CT app, IA will verify DILG CO if it
other contact tracing tool. (_________________________) is integrated with StaySafe.
- Use of manual CT may be considered at the moment.
3 Availability of temperature or thermal scanner (e.g. thermal - Photo of the entrance with thermal scanner/
gun) to assess employees, clients and visitors temperature checking
4 Availability of health declaration sheet for employees and NA if there is an online CT.
clients If no CT, a photo of the form required to be filled up by
employees and clients.
5 Availability of isolation area for identified symptomatic - Photo of the designated are
employees - Internal Memo designating the same (if any)
6 BHERTs and other COVID-19 Emergency hotlines are - Photo the conspicious area with COVID19 Emergency
placed in conspicious area. Hotlines
7 Availability of handwashing stations with soap, sanitizers - Photo of handwashing stations/ sanitizers used by the
and hand drying equipment or supplies for employees and Office
clients/visitors in strategic location in the establishment
8 Installed physical barriers in enclosed areas to maintain - Photo Office Setup with physical barriers, markers or
social distancing(blocking off chairs, markers, stickers on the floor stickers to help maintain social distancing
floor for spacing)
9 Availability of personnel-in-charge for monitoring and - Memo - Designation of Personnel-in-Charge of
maintaining social distancing and ensuring the compliances monitoring and maintaining social distancing and of
of clients/visitors/employees to health protocols and areas in ensuring the compliances of clients/ vistors/ employees to
the establishment where people gather(e.g. queue) health protocols
10 Availability of windows for adequate air exchange in - Photo of air purifier in the Office (if available)
11 enclosed(indoor)
Compliance to theareas as citedprotocol
disinfection in DOLE in Department
accordance Order
with -- Or,
MemoPhoto of ProperofAir
re Conduct Ventilation
Regular of the Office
Disinfection/ Disinfection
No.
DOH224-21 or the Memorandum
Department Guidelines on No.
Ventilation
2020-157for and
Workplaces
0157-A Protocol
andthe
or Public Transport
"Guidelines on to Preventand
Cleaning andDisinfection
Control theinSpread of
Various - Sample photo of office disinfection
COVID-19
Settings as an Infection 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.
12 Personnel, employees, clients and visitors always wear - Memo for Employees
13 facemasks
Establishedand facesystem
referral shields for
especially
medicalin enclosed
and places.
psychosocial -- Photo ofMOA/
Copy of signages re reminder
Implementing to wear facemasks
Procedures re referraland
services. faceshields
system for medical and psychosocial services
14 Availability of designated Safety Officer with the following - Memo specifying the name/s of the safety officer/s
functions
a.) coordinate with the appropriate bodies for support and
referral to 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
15 Availability of employees
of storage facility for quarantined or isolated;
proper collection, and - Photo of the disposal facility/ mechnism for infectious
treatment,
d.) implement
and disposal ofreturn
used to work policies.
facemasks and other infectious waste
I hereby certify that the facts stated herein are true and correct of my own personal knowledge and any misrepresentation
wastes. 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