Courtesy of Mount Sinai
As we transition to reopening the economy, employers, unions, and community-based organizations face many new health and safety challenges arising from SARS-CoV-2 (COVID-19). The Mount Sinai Selikoff Centers for Occupational Health are leaders in workplace safety and aim to help organizations develop plans to mitigate risk for coronavirus exposure and set up programs to protect workers. Our team of occupational health physicians and health and safety professionals have developed the general guide below for diverse organization types and industries to assist with safe return to work. If you would like tailored support, connect with us at firstname.lastname@example.org or 212-824-7118 to learn more.
We can support your organization with the following services:
- One-on-one consultations to provide tailored guidance to meet your needs
- Virtual site visits to evaluate workplace safety, layout, and flow
- Return-to-Work medical screenings
- Ergonomics and injury prevention programs
- Medical clearance for respirator use
- Education and training
* The COVID-19 Return to Work Guide is not intended to provide medical, legal, or other professional advice. The Guide is for general information purposes only. Before finalizing a return to work plan, we recommend that you obtain advice from qualified professionals.
To the fullest extent allowed by law, the Icahn School of Medicine, including The Mount Sinai Selikoff Center for Occupational Health, and their affiliates within The Mount Sinai Health System (collectively, “Mount Sinai”), disclaim all representations as to the accuracy or completeness of this guide.
Mount Sinai will not be liable for any errors or omissions in content or for any losses, injuries, or damages arising from the display or use of content.
How to Successfully Reopen for Business
Developing a multi-faceted and dynamic COVID-19 risk reduction strategy is key to a safe, sustained reopening. As a first step, designate a Return-to-Work (RTW) team that understands your work sites, processes, and potential COVID-19 exposure scenarios. At the end of procedure and policy development, you should produce a written document that details your RTW Program. Your written plan should be considered a living document that will be reviewed periodically and modified as we learn more about risk mitigation of viral transmission and the most effective precautions. Here are the elements to include in your program:
- Risk Mitigation Strategies
- Space Design and Social Distancing
- Personal Protective Equipment (PPE)
- Cleaning and Disinfecting
- Hand Hygiene
- Engineering Solutions
- Screening of Workers
- Education and Training
- Updates on Available Testing
- Wellness and Mental Health
- Commuting and Travel
- ADA Compliance and Families First Coronavirus Response Act
- Lactation Accommodations in the Workplace
- OSHA’s COVID-19 Recordkeeping Rule
- Supporting Documents and Resources
The way you roll out your RTW Program is important. Communicate the RTW Program and instructions to all employees and share customer-directed information publicly. Your program should encourage adherence and awareness by systematically sharing up-to-date information.
We suggest communicating clearly, in a straightforward and supportive tone. You should have an employee attestation confirming that they have reviewed the information both prior to and on the day of return. We recommend sharing information redundantly—repeated multiple times and in written and oral formats so that messaging is more easily understood and followed.
Important characteristics of communication to consider:
- Tone of verbal and written communication
- Critical nature of the information
- Open door policy for questions
- An established point person and time frame to obtain answers to questions
- How to obtain support if needed
Risk Mitigation Strategies
Conduct a risk assessment to identify potential workplace exposures to COVID-19. This systematic survey and examination of risk factors will guide you in developing your risk mitigation strategy. Conduct a separate assessment at each work site as different locations may pose different hazards. Whenever possible, your strategy should have redundancy, including masking, distancing, and disinfection, to ensure maximized safety. The risk mitigation strategies you develop as part of your RTW Program should not conflict with existing site safety and health protocols.
Eliminating the exposure at its source is the most effective risk mitigation strategy. Below are various risk mitigation factors that you should consider.
Space Design and Social Distancing
While working remotely is an optimal way to ensure social distancing, many businesses will require individuals to be present part-time or full time to perform work on-site, provide customer support, or interact with the public for sales or services. Review your operational flow chart to identify potential exposure scenarios. We recommend keeping six feet of distance between individuals as much as possible. To do this, you may need to modify your facility plan, activity flow, and locations of your work areas. Be sure to review the flow chart for all types of full-time and part-time employees, such as drivers, sales staff, cleaners, night shift workers, and non-employees, such as delivery people, consultants, cleaning staff, and visitors.
Once facility flow is assessed, hang signage for proper direction of movement, guides for social distancing, and statements of space capacity, especially in areas where there might be a wait for entry or in common areas such as lunch areas, restrooms, stairwells, hallways, and elevators. Signage should be visible as people enter and exit spaces. The goal of signage is to clarify instructions so that individuals can move about safely and bottlenecks of traffic do not form. Consider providing signage translated into commonly used languages based on your worker population or customers.
For smaller spaces where social distancing cannot be implemented, we recommend modified and staggered work schedules to limit the number of employees on location at any one time. You may also consider, when possible, relocating activities to an outdoor space to reduce exposure. Prior to this, a qualified individual familiar with the operation (union representative, foremen, company safety representative) must examine the space to ensure that it does not present a safety or health hazard.
Personal Protective Equipment (PPE)
Personal protective equipment (PPE), such as masks, gloves, and face shields have been frequently used source of control during the COVID-19 pandemic. PPE is an effective risk reduction tool, especially when used alongside other controls to provide an additional level of protection. PPE does have limitations that often reduce its effectiveness; it must be used correctly to be effective, and it places the burden on employees.
Masks, such as surgical masks, will reduce potential exposure (infectious respiratory droplets) from one worker to the other. Respirators, such as an N95, are designed to protect the user from exposure. Effective masking policies require buy-in from everyone. Employers who provide N95s or other types of respirators must follow the OSHA respirator program (1910.134) requirements, such as the selection of the appropriate respirator, medical clearance, training, and fit testing.
We recommend that you implement the use of appropriate face coverings as per the CDC and your local Health Department guidance.
Cleaning and Disinfecting
The virus can spread through touching contaminated surfaces or objects, then touching your face, especially the area near your mouth, nose, or eyes (mucus membranes).
Disinfection is the process of inactivating or killing microorganisms. Cleaning work areas is the first step of the disinfection process. Cleaning removes grime and dirt that might inhibit disinfection. Create a list of areas that need to be disinfected. Disinfection should concentrate on high contact areas such as door handles, desks, elevator buttons, sign-in clocks, and tools. The frequency of cleaning and disinfection will be based on work site conditions, work tasks, usage, environmental conditions, and other factors. Based on your risk assessment, other non-high contact areas may require scheduled disinfection.
The Environmental Protection Agency (EPA) maintains a list of effective disinfectants for use against COVID-19. When selecting a disinfectant, you should review its toxicity* and recommended contact time, also referred to as wet time—the time that the product must remain wet to be effective. Select the least toxic product that will effectively eliminate the microorganism. Be aware that many disinfectants contain hazardous chemicals such as Quaternary Ammonium Compounds (QACs), bleach, or other toxic chemicals. Never mix bleach with any cleaning products. Mixing bleach with ammonia products, rubbing alcohol or acids, like vinegar will create dangerous gases. Gaseous products can be deadly if concentrations are high enough.
Follow these steps to limit exposure to harmful chemicals:
- Review the manufacturer’s instructions before using any disinfectant.
- Use safe work practices, such as increased ventilation to reduce exposure level.
- Use disinfectant wipes or apply the disinfectant to a cloth and use the cloth to disinfect the surface so as not to aerosolize disinfectants by spraying them onto surfaces.
- Do not self-dilute full-strength disinfecting agents. Use pre-mixed products.
- Place cloths or other items used to apply the disinfectant into trash receptacles with self-closing lids.
- Close containers after use.
- Use recommended personal protective equipment (gloves, eye protection, protective garments, and respirators). Note that N-95 respirators, often used for protection from the COVID-19 virus, only filter out particulates, like mold spores, dust, and microorganisms (viruses).
* Safety Data Sheets list most, but not all the toxic chemicals in the product. Manufacturers are required to list hazardous products that are greater than 1% of the total or 0.1 % of ingredients that are known carcinogens.
Promote healthy hand hygiene practices with signage, education, and training.
Frequent hand hygiene is an effective way to reduce the spread of COVID-19. Vigorous handwashing with warm water and soap for at least 20 seconds will kill the virus. An effective substitute for soap and water is an alcohol-based hand sanitizer with 60% ethanol or 70% isopropanol. Hand disinfectants containing methanol can result in methanol poisoning and should never be used.
An effective hand hygiene program requires frequent hand sanitizing. Providing conveniently located wash stations or hand sanitizing dispensers will enable an effective hand hygiene program. Additional handwashing should take place throughout the day, especially before, during, and after food preparation, and after using the toilet, blowing your nose, coughing, sneezing or touching the garbage.
Engineering solutions, such as using ventilation to mitigate the spread of the virus can reduce exposure by increasing the number of air changes/hour and the percentage of outside air used by the system. Simply opening your windows when possible can help dilute contaminants in the air. You also may consider installing higher rated filters* in the HVAC system. Using portable HEPA air filtering units may augment the HVAC system. Check portable air purifiers before purchasing to ensure they do not produce ozone, a known respiratory irritant. Installing effective work barriers, such as acrylic shielding, between employees or between employees and the public can help reduce droplet transmission. Ensure that bathrooms are vented to the outside and each toilet has a seat cover to reduce fecal COVID-19 aerosol transmission.
* You should consult with HVAC manufacturer or service provider before changing filters or modifying your system settings.
Return-to-Work Medical Screenings
Even though the RTW Program is designed to mitigate risk, some employees may have medical conditions that place them at a higher risk of severe illness if infected with COVID-19 and may require additional safeguards. We recommend that these employees be assessed either by their primary care physician or by an occupational medicine physician with experience in evaluating workplace hazards as it relates to employee risk. Depending on the degree of risk for an individual worker, the physician may make recommendations for accommodations such as remote work, job reassignment, increased barriers, or enhanced personal protective equipment (PPE).
Front Door Screening
We recommend that employers establish a process to screen incoming employees, contractors, and visitors before they arrive at your facility or at the entrance of the facility. Before you set up a front door screening, you should consider which personnel will have access to confidential personal health information provided by your employees.
Screening protocols prior to entry may consist of (1) temperature checks completed with a personal thermometer prior to arriving or completed in-person using non-contact thermometers, (2) a symptoms check and (3) a specific assessment of the risk of coronavirus exposure. If the individual has a fever or answers “yes” to the symptom check and the assessment of risk of exposure, the individual should not enter the facility. They should be referred to their primary care physician for further recommendations on treatment and quarantine or isolation and should have a safe way to be transported home, or to a healthcare facility if needed. Appropriate controls to permit entry, such as putting on masks, face shields, or goggles, and instructions on how to proceed after entering should be provided after screening and prior to entry.
The CDC does not recommend requiring employees to provide a negative COVID-19 test result or a doctor’s note after a sick employee recovers from COVID-19 and is ready to return to work. Returning to work after COVID-19 infection should be based on either a symptom-based or time-based strategy. See the CDC’s updated guidance. Recommended duration of isolation varies with illness severity and the employee’s underlying medical problems. A qualified health care professional, such as the employee’s primary care physician or another treating physician or provider should make the decision to discontinue isolation. The CDC recommends implementing flexible sick leave policies and identifying a workplace coordinator to deal with COVID-19 impact on the workplace.
If an employee returning after an illness has a change in their work capabilities and requires accommodations to enable them to work, an assessment performed by a qualified physician can help determine an employee’s ability to perform specific tasks and essential job functions. See below for more information on Request for Accommodation applications under the American With Disabilities Act (ADA).
Education and Training
Exposure to COVID-19 is not limited to the workplace. COVID-19 employee education should include a review of symptoms, discussion of primary (respiratory) and secondary (contact with contaminated surfaces) routes of transmission, and the importance of distancing, disinfection, masking, and other effective mitigation practices outside of the workplace including information on safe practices for inside the home. Encourage vigilance and continued safe practices. On-going employee education on personal and community safety is important to creating a safe workplace.
Updates on Available Testing
Three types of tests for COVID-19 are currently approved by the Food and Drug Administration (FDA) under the emergency use authorization (EUA).
- COVID-19 ANTIGEN TEST: An antigen is a substance that induces an immune response. On May 9, 2020, the FDA issued emergency use authorization (EUA) for a new category of tests that have the advantage of rapidly detecting viral particles from samples collected by nasal swabs. Under the EUA these tests are authorized for point-of-care testing. According to the FDA statement, “Antigen tests are very specific for the virus but are not as sensitive as molecular PCR (Polymerase Chain Reaction) tests. This means that positive results from antigen tests are highly accurate, but there is a higher chance of false negatives, so negative results do not rule out infection.”[i] A positive test means that the person has COVID-19. A negative test may not exclude infection or prevent the possible spread of the virus and should be confirmed by other testing. These tests have the advantage of lower cost, simpler design, and rapid results. As of July 6, 2020, there are two antigen tests that are authorized under the EUA.
- COVID-19 MOLECULAR TEST: Molecular tests or PCR tests detect the presence of COVID-19 virus genetic material—viral RNA. These tests are believed to be highly accurate and according to the FDA both positive and negative tests are likely to be reliable. These tests offer the advantage of accurate determination of infected versus non-infected persons but have limitations in turn-around time for the test results, as well as regional variation in test availability. All but one currently authorized molecular tests must be done at a doctor’s office. Home-test kits are currently authorized by the FDA under the EUA are available “for use by individuals to self-collect nasal swab specimens at home”.[ii]
- SEROLOGICAL TESTING: These tests detect antibody presence in persons who were ill and mounted an immune response to an infection, such as COVID-19. These tests can help assess whether a previously infected individual has some degree of protection against re-infection with the same virus, might have had an unrecognized infection or one with minimal symptoms, or might have lower disease severity in case of re-infection. In the setting of COVID-19, however, there are multiple limitations to currently utilizing this test for determining the degree of protection from re-infection even in persons who have detectable antibodies to the SARS-CoV-2 virus. Some of these limitations include:
- How accurately the test can detect antibodies specific to the virus that causes COVID-19, versus other coronaviruses.
- The level of antibody titers (i.e. how many antibodies) needed to confer immunity against re-infection with COVID-19 or to decrease the severity of disease in case of re-infection.
- Whether having antibodies protects from re-activation of a virus.
- How long the immunity might last.
Time will be needed for answers regarding lasting immunity and degree of protection from re-infection with COVID-19 for those individuals with antibodies. At the present time, these tests are most useful in convalescent plasma donation for the potential treatment of severely ill COVID-19 patients.
Wellness and Mental Health
The outbreak of COVID-19 has induced a considerable degree of fear, stress, and anxiety across all sectors of the workforce and society. The emotional toll will have a lasting effect on many individuals and their families in the months and years to come. Employers have an opportunity to support their workforce by including wellness and mental health programs as a key component of their RTW Program.
Programs may include:
- Individual, Group, and Family Counseling
- Stress Management, Stress Reduction, and Mindfulness Programs
- Grief and Loss Counseling
- Injury Prevention and Remote Work
- Childcare and Elder Care Assistance
- Peer-to-Peer Support Groups
Commuting and Travel
Once your employees have begun to commute to and from work, education on personal precautions should be provided by the employer. Recommendations for utilizing various means of transportation should be addressed including public transportation, car services, taxis, and personal vehicle usage. Depending on the duration of a commute, you and your employees should assess the safest method of travel and its feasibility. However, when at all possible, working remotely is recommended.
Protective measures should be taken for all means of transportation including the use of masks, avoiding high-frequency touch surfaces, frequent hand sanitizing, disposable glove use, avoidance of touching the mouth, nose, or eyes, and socially distancing. Providing this education prior to employees’ return to work can help to alleviate anxiety over the transition to onsite work and can help to mitigate the risk of exposure while commuting.
See the CDC guidelines for various transportation precautions.
Personal and Work-Related Travel
Personal and work-related travel during the COVID-19 pandemic should be minimized to increase the safety of your employees, their families, and the public. As COVID-19 has spread both internationally and nationally, the travel advisory is frequently changing. Refer to your city, state, and federal websites for national and international travel updates.
Employees should avoid all travel if they are sick or have been exposed to someone who is sick with COVID-19 within the past 14 days. If employees have not been sick, have not been exposed to anyone sick with COVID-19, and must travel during the pandemic, they should refer to the general CDC travel advisory which provides guidance on all known current and past outbreaks.
Lactation Accommodation in the Workplace
Update and share guidelines for lactation room usage to support nursing mothers in the workplace. Address issues related to how to access the space, utilization of supplies, and cleaning and disinfection practices. Post signage to encourage proper hand hygiene.
ADA Compliance and Families First Coronavirus Response Act
The U.S. Equal Employment Opportunity Commission (EEOC) enforces workplace anti-discrimination laws including the Americans with Disabilities Act (ADA) and the Rehabilitation Act, including the requirement for reasonable accommodation for those with disabilities, and rules about medical examinations and inquiries. The updated guidance was issued on March 21, 2020, addressing return to work issues as businesses begin to reopen or transition employees back to their worksite.
The Families First Coronavirus Response Act (FFCRA) signed into law on March 18, 2020, expands the Family and Medical Leave Act (FMLA) temporarily (until the end of December 2020) to cover leave and loss of income when an employee needs to care for children without school or childcare because of the COVID-19 pandemic. Additionally, it provides for two weeks of paid sick leave for childcare and other leave and provides tax credits related to the paid leave.
- Employer Requirements and the ADA: When planning a return to work, employers must meet all public safety codes, building codes, applicable laws, and security requirements. ADA requirements must not be compromised concerning the public and employees.
- ADA Qualifying Conditions: Concerns most often are centered on individuals who may be at higher risk for developing complications related to COVID-19. This may also include older adults as identified by the Centers for Disease Control and Prevention (CDC).
Employers must address these concerns, which could encompass but are not limited to individuals with chronic medical conditions such as diabetes, lung or heart disease, and those who are immunocompromised, or workers with residual symptoms as a result of having the virus. If a medical provider’s recommendation is preventative in nature, a relationship between the disabling condition and the accommodation request should be provided by the employee (or their physician) to demonstrate that, if infected by the COVID-19 the employee could experience medical complications.
Consideration must be given to measures that reduce employee exposure to the virus as these requests are categorized as ADA-related. An employer must consider these types of requests and must engage in a dialogue with the employee to identify reasonable accommodations, barring undue hardship to the employers.
- Parameters for a Disabling Condition: Reasonable accommodations under the federal ADA requires that an individual must have an established record as outlined in the ADA Amendments Act. To be eligible to receive workplace reasonable accommodations under the federal ADA, an individual must have a record of a disability, as defined by law.
- Confidentiality: According to the EEOC, the ADA requires that all medical information about a particular employee be stored separately from the employee’s personnel file, thus limiting access to this confidential information. An employer may store all medical information related to COVID-19 in existing medical files. This includes an employee’s statement that he has the disease or suspects he has the disease, or the employer’s notes or other documentation from questioning an employee about symptoms.
- Accommodations: If it is determined that job accommodation is possible, the employer must do their utmost to implement these modifications barring undue hardship. This might include changes to employee assignments, types of job tasks to perform, shifts in work hours, and when possible, an employee performing their job duties from home. A flexible mindset is important to maintain a strong employer-employee relationship as these changes can be temporary in nature.
OSHA’s COVID-19 Recordkeeping Rule
OSHA’s COVID-19 recordkeeping rule is applicable to all employers. The interim guidance states that COVID-19 is a recordable illness but that it is time-limited to the current COVID-19 public health crisis. All employers are responsible for recording COVID-19 cases. COVID-19 is a respiratory illness and should be coded as such on the OSHA Form 300.
Criteria to be followed:
- An individual with at least one positive respiratory test for SARS-CoV-2.
- The case is work-related as defined by 29 CFR 1904.5
- The case involves one or more of the following criteria set forth under general recording 29 CFR 1904.7:
- Death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, loss of consciousness, involves significant injury or illness diagnosed by a physician or health provider even if it does not result in the above mentioned (3a-3e).
OSHA Compliance Safety and Health Officers (CSHO) will exercise discretion on enforcement if the employer has complied with this obligation and has made a reasonable determination of work-relatedness including:
- The reasonableness of the employer’s investigation into work-relatedness.
- The evidence available to the employer.
- The evidence that a COVID-19 illness was contracted at work, i.e. development of illness in clusters of workers who work together, or close exposure to the public in areas of high community transmission. If the employer cannot determine if the exposure was likely in the workplace, the employer does not need to record that COVID-19 illness.
Checklists and Guidance Documents
For a list of resources about COVID-19, refer to the following information below.
- COVID-19 Front Door Screening
- Hearing Impaired COVID-19 Symptom Check
- COVID19 Travel Considerations
- COVID19 Return to Work Guide
- New York State (NYS) Dept of Health – COVID-19
- NYS Workers’ Compensation
- NYS Resources for workers
- Paid Leave Law
- NYC Community Resources
- OSHA Guidance on Preparing Workplaces for COVID-19
- OSHA COVID-19
- NIOSH Coronavirus Disease 2019
- CDC Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes
- WHO Coronavirus disease (COVID-19) technical guidance: Guidance for schools, workplaces & institutions
- National COSH Coronavirus Resources for Workers
- ACOEM COVID Resources
- Infectious Diseases Society of America
- CDC COVID-19 Pregnancy & Breastfeeding
- CDC Proper Storage & Prep of Human Milk & Safe Cleaning Practices
- The World Alliance for Breastfeeding Action (WABA)
Wellness & Mental Health Resources