Mandatory COVID-19 Vaccination Policy Template

This sample policy was developed by Missouri Hospital Association and has not been approved

by any outside authority, such as the Centers for Medicare & Medicaid Services. MHA strongly

recommends you consult with counsel familiar with your hospital’s operations.

The contents of this publication are intended to convey general information only and do not

constitute legal advice. This publication does not constitute or create an attorney-client

relationship.

Mandatory COVID-19 Vaccination Policy Template

This policy requires all employees to be fully vaccinated against COVID-19, as defined by the Centers for

Medicare & Medicaid Services Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule (

FR 61555), unless entitled to an exemption by law. Individuals who cannot be vaccinated because of a

medical contraindication to COVID-19 vaccines, a qualifying disability under the Americans with

Disabilities Act, medical necessity that requires delay in vaccination, a sincerely held religious belief

subject to Title VII of the Civil Rights Act of 1964 or other valid reason under applicable federal and state

law may be exempted from this policy, subject to other mitigation requirements.

CMS requires that hospitals establish, implement, and enforce a written COVID-19 vaccination policy

that requires covered individuals to comply with a mandatory vaccination policy. Workforce members

who are covered by the rule include all hospital staff, licensed practitioners, students, trainees,

volunteers and any other individual providing care, treatment or other services for the hospital and/or

its patients under contract or by other arrangement. Individuals covered by the policy may include those

who work in facilities owned and/or operated by the hospitals and subject to the CMS interim rule,

which include:

o Ambulatory Surgical Centers

o Hospices

o Psychiatric residential treatment facilities

o Programs of All-Inclusive Care for the Elderly

o Hospitals (acute care hospitals, psychiatric hospitals, hospital swing beds, long term care

hospitals, children’s hospitals, transplant centers, cancer hospitals, and rehabilitation

hospitals/inpatient rehabilitation facilities)

o Long Term Care Facilities, including Skilled Nursing Facilities and Nursing Facilities,

generally referred to as nursing homes

o Intermediate Care Facilities for Individuals with Intellectual Disabilities

o Home Health Agencies

o Comprehensive Outpatient Rehabilitation Facilities

o Critical Access Hospitals

o Clinics, rehabilitation agencies, and public health agencies as providers of outpatient

physical therapy and speech-language pathology services

o Community Mental Health Centers

o Home Infusion Therapy suppliers

o Rural Health Clinics/Federally Qualified Health Centers; and

o End-Stage Renal Disease

Hospitals are not required to use this template. If you choose to use this document, you will need to

complete highlighted text and modify this document to accurately represent your facility’s

circumstances and policies. A hospital must add to or revise this template to ensure the final policy

matches the specific procedures that are or will be implemented in their facility. A hospital should

always consult with legal counsel before issuing a final policy. In addition, hospitals should be cognizant

of existing policies and procedures that address issues such as accommodations for medical and

religious reasons, infection prevention and control, and others and ensure all policies and procedures

are in alignment and/or revise existing language.

Hospitals may also wish to consider keeping a log of which policies and procedures were developed or

revised to meet the CMS interim rule. This log could be kept in the hospitals survey manual to ease

pulling documents together for survey purposes.

[Hospital Name] Mandatory COVID-19 Vaccination Policy

Adopted by the Board of Directors and effective as of [Date]

1. Purpose

Vaccination is known to reduce the instance and severity of COVID-19 illness in the workplace. [Hospital

Name] has adopted this policy on mandatory vaccination to safeguard our employees and patients from

the hazards of COVID-19. This policy complies with the Centers for Medicare & Medicaid Services

Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule (86 FR 61555).

Employees not in compliance with this policy will be subject to discipline under [Hospital Name]’s

disciplinary policies.

This policy applies to any employee working in the following locations: [Insert locations, which may

include any facilities owned and/or operated by the hospital subject to the rule, which are listed on page

1, or according to how the hospital maintains policies and procedures within their organization or health

system.]

2. Definitions

“Covered Workforce Member” means any of the following:

• All employees of [Hospital Name], regardless of clinical responsibility or patient contact.

Employees include part-time and as needed (PRN) employees, as well as any employee hired

after the effective date of this policy

• Licensed practitioners

• Students, trainees, and volunteers

• Individuals who provide care, treatment, or other services for [Hospital Name], under contract

or by other arrangement.

Covered Workforce Members do not include Excluded Individuals.

“Excluded Individual” means any individual:

• Who exclusively provide telehealth or telemedicine services outside of the hospital setting and

do not have any direct contact with patients or other Covered Workforce Members

• Who provide support services for the hospital that are performed exclusively outside of the

hospital setting and who do not have any direct contact with patients or other Covered

Workforce Members

“Fully vaccinated” means it has been two weeks or more since an individual has completed a primary

vaccination series for COVID-19. For purposes of the CMS interim final rule, Covered Workforce

Members who have completed the primary vaccination series by January 4, 2022, will be considered

fully vaccinated, even if they have not completed the 14-day waiting period required for full vaccination.

A Covered Workforce Member who has contracted COVID-19 in the past but has not been vaccinated is

not considered to be partially or fully vaccinated. At this time, booster doses are not required as part of

a primary vaccination series for COVID-19.

3. Vaccination Requirements

All Covered Workforce Members must be fully vaccinated no later than January 4, 2022. Covered

Workforce Members will be considered fully vaccinated two weeks after receiving the requisite number

of doses of a particular COVID-19 vaccine regimen, except that staff having received the second dose of

a two-dose vaccine between December 6, 2021, and January 4, 2022 will be considered fully vaccinated

even if they have not completed the 14-day waiting period. An employee will be considered partially

vaccinated and out of compliance with this policy if they have received only one dose of a two-dose

vaccine regimen as of January 4, 2022. Therefore, all Covered Workforce Members must:

o Receive the first dose of a two-dose vaccine or the first dose of a single-dose vaccine by

December 6, 2021; and

a. Receive the second dose of a two-dose vaccine by January 4, 2022.

Any Covered Workforce Member who has not initiated vaccination and does not have an approved

exemption by December 6, 2021, will no longer be able to provide care, treatment or services to the

hospital or its patients.

In accordance with the CMS interim final rule, any newly hired Covered Workforce Member must have

received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine

prior to providing any care, treatment, or other services for the facility and/or its patients.

4. Vaccination Status and Acceptable Forms of Proof of Vaccination

All Covered Workforce Members must provide [Hospital name] documentation of their vaccination

status by December 6, 2021. Covered Workforce Members shall also provide [Hospital name] with

documentation of any change in their vaccination status, including the receipt of any booster dose(s).

Any Covered Workforce Member who fails to inform [Hospital name] of their vaccination status by the

required deadlines will be considered unvaccinated for purposes of this policy.

Covered Workforce Members who fail to provide truthful and accurate information about their COVID-

19 vaccination status, or, if applicable, any testing results will be subject to [Hospital name]’s disciplinary

policy.

Proof of vaccination status can be submitted via [insert how Covered Workforce Members can submit

vaccination information].

Acceptable proof of vaccination status is one of the following:

a. The record of immunization from a healthcare provider or pharmacy

b. A copy of the COVID-19 Vaccination Record Card

c. A copy of medical records documenting the vaccination

d. A copy of immunization records from a public health, state, or tribal immunization information

system

e. A copy of any other official documentation that contains the type of vaccine administered,

date(s) of administration, and the name of the healthcare professional(s) or clinic site(s)

administering the vaccine(s).

Proof of vaccination generally should include the Covered Individual’s name, the type of vaccine

administered, the date(s) of administration, and the name of the healthcare professional(s) or clinic

site(s) that administered the vaccine. The [Hospital name] will still accept the state immunization record

as acceptable proof of vaccination even if it does not include all elements listed above.

5. Leave Time Associated with COVID-19 Vaccination

[Hospital may have existing HR policy according to OSHA Healthcare ETS or other policy to reference

here]

An Employee will be allowed paid leave time, as needed, to receive a vaccination. Leave will be paid at

the Employee’s regular rate of pay for up to [four] hours. Should an employee require more than [four]

hours to get the vaccine, he or she must notify [designated representative] and document the reason

the additional time is needed. Reasonable requests for additional time will be granted, but the time will

be unpaid. An Employee may elect to use accrued leave to cover the additional time.

An Employee experiencing adverse symptoms from the COVID-19 vaccine that prevent them from

working may utilize up to two workdays of [paid sick leave] immediately following each dose. Employees

who have no accrued paid sick leave will be granted up to two days of additional [paid sick leave]

immediately following each dose, if necessary to recover from vaccine side effects.

Employee will follow [Hospital name]’s PTO/sick leave policies and procedures to request and obtain

necessary approvals for time off under this Section.

6. Reporting COVID-19 Infection and Removal from the Workplace

All Covered Workforce Members must promptly notify [designated representative] of they have tested

positive for COVID-19 or been diagnosed with COVID-19 by a licensed healthcare provider.

Covered Workforce Members who are sick or experience COVID-19 symptoms while at home or at work

should communicate those to [Hospital name] pursuant to [reference Hospital policy or process here].

In the event a Covered Workforce Member must be removed from the workplace due to COVID-19,

leave may be administered according to [Hospital name] leave policies [e.g., PTO/sick leave, Family

Medical Leave Act, other policies].

A Covered Workforce Member who has received a positive COVID-19 test or has been diagnosed with

COVID-19 by a licensed healthcare provider will not be permitted to enter/remain in the workplace.

A Covered Workforce Member who has been removed from the workplace because of a positive COVID-

19 test or diagnosis may be eligible to work remotely or in isolation. These eligibility determinations

shall be made in accordance with [reference Hospital remote work policies and procedures].

Covered Workforce Members who are removed from the workplace will be eligible to return to work

when they meet the following criteria:

a. The Covered Individual meets the return-to-work criteria in CDC’s Interim Guidance for

Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 [or per

Hospital policy if different from CDC guidance]

b. The Covered Individual submits a written recommendation to return to work from a licensed

healthcare provider.

Any Covered Individual returning to work pursuant to this policy must submit documentation

demonstrating they meet one of the criteria above to [designated representative].

7. Accommodations for Medical or Religious Reasons or Those Requiring Delayed

Vaccination

Hospitals have two options for how to include these requirements: (1) include the accommodation

provisions here in the mandatory policy; OR (2) move the accommodation process to a separate policy

that would be provided only to employees who are seeking or have received an accommodation. It

could be confusing to have exemptions and additional precautions listed in the mandatory vaccination

policy.

Covered Workforce Members may request an exemption from this mandatory vaccination policy if the

vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination.

Employees also may be legally entitled to a reasonable accommodation if they cannot be vaccinated and

cannot wear a face covering because of a disability, or if the provisions in this policy for vaccination,

and/or testing for COVID-19, and/or wearing a face covering conflict with a sincerely held religious

belief, practice, or observance. Requests for exceptions and reasonable accommodations must be

initiated by [insert instructions].

All such requests will be handled in accordance with the following provisions, as well as [Hospital

name’s] [insert policies and procedures] and other applicable laws and regulations.

[insert any steps, process, communication, or other here]

8. Mitigation Measures To Guard Against the Transmission of COVID-19

[The hospital may have mitigation measures as currently listed in the OSHA Healthcare ETS and

CMS infection control guidance in another policy or procedure. It is appropriate to reference

those policies here along with any additional precautions that be taken.]

[If your hospital does not have a policy or plan due to not being subject to the OSHA Healthcare

ETS, we would highly encourage using the OSHA Plan Template to develop a separate policy

regarding precautions, enhance existing infection control policies or insert into this policy. The

following provisions are examples of adopting mitigation measures in conformance with the

OSHA Healthcare ETS].

[Hospital name] requires all unvaccinated Covered Individuals, in addition to the existing [insert

name of policy or procedure] to adopt the following measures to mitigate against the

transmission of COVID-19:

Personal Protective Equipment (PPE)

[Hospital name] will provide, and ensure that employees wear, facemasks or a higher level of respiratory

protection. Facemasks must be worn by employees over the nose and mouth when indoors and when

occupying a vehicle with another person for work purposes. Policies and procedures for facemasks will

be implemented, along with the other provisions required by OSHA’s COVID-19 ETS, as part of a multi-

layered infection control approach.

Facemasks provided by [Hospital name] will be FDA-cleared, authorized by an FDA Emergency Use

Authorization, or otherwise offered or distributed as described in an FDA enforcement policy. [Hospital

name] will provide employees with a sufficient number of facemasks, which must be changed at least

once a day, whenever they are soiled or damaged, and more frequently as necessary (e.g., patient care

reasons). [Hospital name] may also provide a respirator to employees when only a facemask is required

(i.e., when a respirator is not otherwise required by OSHA’s COVID-19 ETS) and, when doing so, will

comply with OSHA’s COVID-19 ETS mini respiratory protection program (29 CFR 1910.504). [Hospital

name] will also permit employees to wear their own respirator instead of a facemask and, in such cases,

will comply with OSHA’s COVID-19 ETS mini respiratory protection program (29 CFR 1910.504).

Additional information about when respirator use is required can be found below.

[Describe how employees will be provided facemasks and instruction about when and how they should

be worn or used.]

Paragraph (a)(4) of the OSHA Healthcare ETS exempts fully vaccinated employees from the PPE

requirements of the ETS when in well-defined areas where there is no reasonable expectation that any

person with suspected or confirmed COVID-19 will be present. The following are additional exceptions

to [Hospital name] requirements for facemasks:

a. When an employee is alone in a room.

b. While an employee is eating and drinking at the workplace, provided each employee is

physically distanced from any other person, or separated from other people by a physical

barrier.

c. When employees are wearing respirators in accordance with 29 CFR 1910.134 or paragraph (f)

of OSHA’s COVID-19 ETS.

d. When it is important to see a person’s mouth (e.g., communicating with an individual who is

deaf or hard of hearing) and the conditions do not permit a facemask that is constructed of clear

plastic (or includes a clear plastic window). When this is the case, [Hospital name] will ensure

that each employee wears an alternative, such as a face shield, if the conditions permit.

e. When employees cannot wear facemasks due to a medical necessity, medical condition, or

disability as defined in the Americans with Disabilities Act (42 USC 12101 et seq.), or due to

religious belief. Exceptions will be provided for a narrow subset of persons with a disability who

cannot wear a facemask or cannot safely wear a facemask, because of the disability, as defined

with the Americans with Disability Act (42 USC 12101 et seq.), including a person who cannot

independently remove the facemask. The remaining portion of the subset who cannot wear a

facemask may be exempted on a case-by-case basis as required by the Americans with Disability

Act and other applicable laws. When an exception applies, [Hospital name] will ensure that any

such employee wears a face shield, if their condition or disability permits it. [Hospital name] will

provide accommodations for religious beliefs consistent with Title VII of the Civil Rights Act.

f. When [Hospital name] has demonstrated that the use of a facemask presents a hazard to an

employee of serious injury or death (e.g., arc flash, heat stress, interfering with the safe

operation of equipment). [Identify job tasks, if any, in which the use of a facemask presents a

hazard of serious injury or death.] When this is the case, [Hospital name] will ensure that each

employee wears an alternative, such as a face shield, if the conditions permit. Any employee not

wearing a facemask must physically distanced from all other people unless the Hospital can

demonstrate it is not feasible. The employee must resume wearing a facemask when not

engaged in the activity where the facemask presents a hazard.

If a face shield is required to comply with OSHA’s COVID-19 ETS or [Hospital name] otherwise requires

use of a face shield, [Hospital name] will ensure that face shields are cleaned at least daily and are not

damaged.

[Hospital name] will not prevent any employee from voluntarily wearing their own facemask and/or face

shield in situations when they are not required unless doing so would create a hazard of serious injury or

death, such as interfering with the safe operation of equipment.

In addition to providing, and ensuring employees wear, facemasks, [Hospital name] will provide

protective clothing and equipment (e.g., respirators, gloves, gowns, goggles, face shields) to each

employee in accordance with Standard and Transmission-Based Precautions in healthcare settings in

accordance with CDC’s “

Guidelines for Isolation Precautions,” and ensure that the protective clothing

and equipment is used in accordance with OSHA’s PPE standards (29 CFR 1910 subpart I).

[Describe Hospital policies and procedures for providing employees PPE in accordance with Standard

and Transmission-Based Precautions in healthcare settings in accordance with CDC’s “Guidelines for

Isolation Precautions.”]

For employees with exposure to people with suspected or confirmed COVID-19, [Hospital name] will

provide respirators and other PPE, including gloves, an isolation gown or protective clothing, and eye

protection. [Hospital name] will ensure respirators are used in accordance with the OSHA Respiratory

Protection standard (29 CFR 1910.134), and other PPE is used in accordance with OSHA’s PPE standards

(29 CFR 1910 subpart I).

[Describe Hospital policies and procedures for providing PPE to employees with exposure to people with

suspected or confirmed COVID-19.]

For aerosol-generating procedures (AGPs) on a person with suspected or confirmed COVID-19, [Hospital

name] will provide a respirator to each employee and ensure it is used in accordance with the OSHA

Respiratory Protection standard (29 CFR 1910.134). [Hospital name] will also provide gloves, an isolation

gown or protective clothing, and eye protection to each employee, and ensure use in accordance with

OSHA’s PPE standards (29 CFR 1910 subpart I).

[Describe Hospital policies and procedures for providing PPE to employees performing or assisting with

AGPs on a person with suspected or confirmed COVID-19. Note that Hospitals are encouraged to select

elastomeric respirators or powered air-purifying respirators (PAPRs) instead of filtering facepiece

respirators for AGPs on a person with suspected or confirmed COVID-19.]

[Hospital name] and the COVID-19 Safety Coordinator(s) will work collaboratively with non-managerial

employees or representatives to assess and address COVID-19 hazards, including when there is

employee exposure to people with suspected or confirmed COVID-19. [OSHA’s COVID-19 Healthcare

Worksite Checklist & Employee Job Hazard Analysis may be used.]

Aerosol-generating procedures (AGPs) on a person with suspected or confirmed COVID-19

When an AGP is performed on a person with suspected or confirmed COVID-19, [Hospital name] will:

• Provide a respirator and other PPE, as discussed in the previous section

• Limit the number of employees present during the procedure to only those essential for patient

care and procedure support

• Ensure that the procedure is performed in an existing airborne infection isolation room (AIIR), if

available

• Clean and disinfect the surfaces and equipment in the room or area where the procedure was

performed, after the procedure is completed

[Hospital name] and the COVID-19 Safety Coordinator(s) will work collaboratively with non-managerial

employees and their representatives to assess and address COVID-19 hazards while performing AGPs.

[OSHA’s COVID-19 Healthcare Worksite Checklist & Employee Job Hazard Analysis may be useful.]

Physical Distancing

[Hospital name] will encourage unvaccinated employees to physically distance, unless it can be

demonstrated that such physical distance is not feasible for a specific activity. Where maintaining

physical distance is not feasible, [Hospital name] will ensure unvaccinated employees are as far apart

from other people as possible. Physical distancing will be implemented, along with the other provisions

required by OSHA’s COVID-19 ETS, as part of a multi-layered infection control approach.

[Hospital name] and the [COVID-19 Safety Coordinator(s)] will work collaboratively with non-managerial

employees and their representatives to assess physical distancing in the workplace. [OSHA’s COVID-19

Healthcare Worksite Checklist & Employee Job Hazard Analysis may be used to identify, develop, and

implement physical distancing measures for employee protection, and identify fixed work locations

where physical distancing cannot be maintained between employees and co-workers, customers,

visitors, and other non-employees, as well as controls and practices that can be implemented to protect

employees in these fixed work locations.]

[Describe how workplace flow, such as signs and floor markings to indicate where employees and others

should be located or their direction and path of travel, will be adjusted to ensure physical distancing.]

[Describe physical workplace changes, such as increased distance between workstations, check-in and

checkout stations, etc., that will be implemented to ensure physical distancing.]

[Describe how people in the workplace will be prevented from gathering in groups in common areas and

“bottlenecks,” including corridors, meeting rooms, stairways, breakrooms, entrances, exits, and

elevators.]

[Describe how aisles, tables, counters, check-in and checkout stations, etc. will be arranged and how the

flow will be directed to allow for physical distancing between people.]

[Identify protocols such as telehealth, telework, flexible work hours, staggered shifts, or additional shifts

that can be used to reduce the number of employees in the workplace at one time.]

Physical Barriers

[Hospital name] will install physical barriers at each fixed work location outside of direct patient care

areas where the unvaccinated employee is not separated from all other people by an appropriate

distance and spacing cannot be increased, unless it can be demonstrated that it is not feasible to install

such physical barriers. Physical barriers will be implemented, along with the other provisions required by

OSHA’s COVID-19 ETS, as part of a multi-layered infection control approach.

[Hospital name] and the COVID-19 Safety Coordinator(s) will work collaboratively with non-managerial

employees and their representatives to identify where physical barriers are needed. [OSHA’s COVID-19

Healthcare Worksite Checklist & Employee Job Hazard Analysis may be used to identify where to install

physical barriers for employee protection from COVID-19. Physical barriers are not required in direct

patient care areas or resident rooms.]

[Describe where and how physical barriers will be installed when physical distancing cannot be

consistently maintained and spacing cannot be increased. For example:

• Where:

o Public facing fixed workstations (e.g., entryway/lobby, check-in desks, triage, hospital

pharmacy windows, bill payment)

o Security screening and checkpoints

• How:

o Free-standing on the floor and secured

o Mounted securely to hard surfaces above the floor (e.g., benches, desks, countertops,

production lines, vehicle interior surfaces)

o Hung from above and extending down from the ceiling or other fixture and secured so

as not to fall, flap, or move]

Cleaning and Disinfection

[Hospital name] has policies and procedures for cleaning, disinfection, and hand hygiene, along with the

other provisions required by OSHA’s COVID-19 ETS, as part of a multi-layered infection control approach.

[Hospital name] and the [COVID-19 Safety Coordinator(s)] will work collaboratively with non-managerial

employees and their representatives to implement cleaning, disinfection, and hand hygiene in the

workplace. [OSHA’s COVID-19 Healthcare Worksite Checklist & Employee Job Hazard Analysis may be

used to assess COVID-19-related hazards and develop, revise and implement policies and procedures for

cleaning and disinfection.]

In patient care areas, resident rooms, and for medical devices and equipment [may reference existing

policies here]:

[Hospital name] will follow standard practices for cleaning and disinfection of surfaces and

equipment in accordance with CDC’s “

COVID-19 Infection Prevention and Control

Recommendations” and CDC’s “Guidelines for Environmental Infection Control.”

In all other areas:

[Hospital name] requires the cleaning of high-touch surfaces and equipment at least once a day,

following manufacturers’ instructions for the application of cleaners.

When a person who is COVID-19 positive has been in the workplace within the last 24 hours,

[Hospital name] requires cleaning and disinfection, in accordance with CDC’s “Cleaning and

Disinfecting Guidance

,” of any areas, materials, and equipment that have likely been

contaminated by that person (e.g., rooms they occupied, items they touched).

[Describe the schedule for cleaning and disinfection, the persons responsible for conducting cleaning

and disinfection, the products that are used to clean and disinfect the workplace, how the business will

clean patient care areas, resident rooms, and medical devices and equipment, and how the business will

clean and disinfect the workplace if a COVID-19 positive person has been in in the workplace within the

last 24 hours. Attach copy of cleaning logs to be used.]

[Hospital name] will provide alcohol-based hand rub that is at least 60% alcohol or provide readily

accessible hand washing facilities. In addition, signs will be posted encouraging frequent handwashing

and use of hand sanitizers.

[Describe how necessary hand washing and/or sanitizer facilities will be provided, supplied, and

maintained; and how employees will be allowed to perform hand hygiene to meet this requirement.

May also describe how hand washing and/or sanitizer facilities will be provided for use by other persons

entering the workplace.]

Ventilation

[This section applies to Hospitals who own or control buildings or structures with an existing heating,

ventilation, and air conditioning (HVAC) system.]

[Hospital name] will implement policies and procedures for each facility’s heating, ventilation, and air

conditioning (HVAC) system and ensure that:

• The HVAC system(s) is used in accordance with the manufacturer’s instructions and the design

specifications of the HVAC system(s)

• The amount of outside air circulated through the HVAC system(s) and the number of air changes

per hour are maximized to the extent appropriate

• All air filters are rated Minimum Efficiency Reporting Value (MERV) 13 or higher, if compatible

with the HVAC system(s); if not compatible, the filter with the highest compatible filtering

efficiency is used

• All air filters are maintained and replaced as necessary to ensure the proper function and

performance of the HVAC system

• All intake ports that provide outside air to the HVAC system(s) are cleaned, maintained, and

cleared of any debris that may affect the function and performance of the HVAC system(s)

• Existing airborne infection isolation rooms (AIIRs), if any, are maintained and operated in

accordance with their design and construction criteria

Ventilation policies and procedures will be implemented, along with the other provisions required by

OSHA’s COVID-19 ETS, as part of a multi-layered infection control approach. [Hospital name] will identify

the building manager, HVAC professional, or maintenance staff member who can certify that the HVAC

system(s) are operating in accordance with the ventilation provisions of OSHA’s COVID-19 ETS and list

the individual(s) below.

[Describe additional measures to improve building ventilation in accordance with “CDC’s Ventilation

Guidance”. For example:

• Opening windows and doors during work hours when outdoor climate allows, and when doing

so would not present other health or safety hazards

• Placing fans in windows, but not where potentially contaminated air flows directly from one

person to another

• Running the HVAC system for at least 2 hours before and after the building is occupied

• Using portable high-efficiency particulate air (HEPA) fan/filtration systems

• Other measures identified by the Hospital]

[OSHA’s COVID-19 Healthcare Worksite Checklist & Employee Job Hazard Analysis may be used to assess

the HVAC system and develop and implement ventilation measures for the workplace.]

Health Screening and Medical Management

• Health Screening

[Hospital name] will screen each employee before each workday and each shift.

[Describe how employees will be screened or reference existing policy. OSHA’s Sample Employee

COVID-19 Health Screening Questionnaire may be useful.

• Employee Notification to Hospital of COVID-19 Illness or Symptoms

[Hospital name] requires employees to promptly notify [designated representative] of they have tested

positive for COVID-19 or been diagnosed with COVID-19 by a licensed healthcare provider.

[Describe how employees are to notify the hospital or reference existing policy.]

• Hospital Notification to Employees of COVID-19 Exposure in the Workplace

[Hospital name] will notify employees if they have been exposed to a person with COVID-19 at their

workplace

[Describe how you will notify employees of COVID-19 exposure or reference existing policy. For more

information, see OSHA’s Hospital Notification Tool.]

• Medical Removal from the Workplace

[Hospital name] has implemented a policy for removing employees from the workplace in certain

circumstances. [Hospital name] will immediately remove an employee from the workplace when:

[Describe Hospital policies for removing employees from the workplace. For more information, see

OSHA’s Notification, Removal, and Return to Work Flow Chart for Hospitals and Employees.]

[(Note: This list represents the minimum medical removal requirements for compliance with OSHA’s

COVID-19 ETS. The full list of COVID-19 symptoms provided by the CDC includes additional symptoms

not listed above. Hospitals may choose to remove or test employees with additional symptoms from the

CDC list, or refer the employees to a healthcare provider.)]

[Hospital name] will not subject its employees to any adverse action or deprivation of rights or benefits

because of their removal from the workplace due to COVID-19.

9. Confidentiality and Privacy

All medical information collected from individuals, including vaccination information, test results, and

any other information obtained because of testing, will be treated in accordance with applicable laws

and policies on confidentiality and privacy of an employee’s health records.

10. Questions

Please direct any questions regarding this policy to [designated representative].

For additional information about COVID-19 vaccines, employees should consult the CDC's "Key Things to

Know About COVID-19 Vaccines," at

https://www.cdc.gov/coronavirus/2019-

ncov/vaccines/keythingstoknow.html.