Safety Seal Certification Checklist

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 Authority)
Control No.: Date: November 16, 2021
Name of Government Agency/ Office: LGU - BAGUIO CITY
Name of Government Establishment/ Department/ Office/ Unit : HEALTH SERVICES OFFICE
Nature of Government Establishment/ Department/ Office/ Unit: MAIN OFFICE
Address:_BHD Compound, T. Alonzo Barangay, Baguio City
Name of Person in Charge:_Charles Bryan C. Carame Contact Details:_(+63) 9206106376
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 conspicuous area with
conspicuous 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 Installed physical 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 - Memo - Designation of Personnel-in-
distancing and ensuring the compliances of clients/visitors/employees to Charge of monitoring and maintaining
health protocols and areas in the establishment where people social distancing and of ensuring the
gather(e.g. queue) compliances of clients/ visitors/
employees to health protocols
9 Availability of windows for adequate air exchange in enclosed(indoor) - 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. mechanism 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.
Charles Bryan C. Carame / Nov. 16, 2021

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

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Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

SAFETY SEAL CERTIFICATION CHECKLIST

Control No.: Date: November 16, 2021

Name of Government Agency/ Office: LGU - BAGUIO CITY

Name of Government Establishment/ Department/ Office/ Unit : HEALTH SERVICES OFFICE

Nature of Government Establishment/ Department/ Office/ Unit: MAIN OFFICE

Address:_BHD Compound, T. Alonzo Barangay, Baguio City

Name of Person in Charge:_Charles Bryan C. Carame Contact Details:_(+63) 9206106376

# REQUIREMENTS MOVs to be Produced/ Uploaded YES NO N/A Reason why N/A

Charles Bryan C. Carame / Nov. 16, 2021

FOR ONSITE VALIDATION/ INSPECTION

DEFECTS / DEFICIENCIES NOTED DURING INSPECTION:

Name and Signature of Safety Seal Inspector / Date

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