Social Services Custom Policy Manual Order Form

Name of Organization/Location *

Name Location

Name of Individual Completing the Form; *

First Name Last Name

Email *

example@example.com

Phone Number

Please enter a valid phone number.

Do you want your Company Logo included in the Policy Manual?

Yes No

Add Company Logo *

Please select the types of services that are offered at this location; (check all that apply) *

Congregate Living/ Long-Term Stay (14+ days) Childcare/ Daycare Services Mental Health/ Counselling Addiction Services Food Preparation In-Home Services

Please provide the name/type of disinfectants for the following areas;

Wipes;

Sprays;

Floors;

Bathrooms;

Hard Surfaces;

Toys/ Shared Items;

How are groceries brought to this location? *

Delivery Dedicated Staff for Pick-up No specific grocery policy Not Applicable

Do you currently have a specific procedure for the following (click all that apply); if not, a generic policy will be included in your manual.

Blood/ Body Fluid Clean-up and Exposure Preparation/ Administration of Medication Food Preparation Boil Water Advisory

Please describe your procedure for Blood/ Body Fluid Clean-up and Exposure; *

You may upload a copy of your Blood/ Body Fluid Clean-up and Exposure policy;

Please describe your procedure for Preparation/ Administration of Medication; *

You may upload a copy of your Preparation/ Administration of Medication policy;

Please describe your procedure for Food Preparation; *

You may upload a copy of your Food Preparation policy;

Please describe your procedure for Boil Water Advisory; *

You may upload a copy of your Boil Water Advisory policy;

Who is responsible for Environmental Cleaning at this location? *

Third-Party/ Hired Cleaners Dedicated Cleaning Staff Site Staff perform Cleaning Duties

Is there fabric upholstered furniture on-site? *

Yes No

Please describe the procedure for cleaning the surfaces of the upholstered furniture noted above (including frequency); *

Do you currently have a specific procedure for the following (click all that apply); if not, a generic policy will be included in your manual.

Cleaning of Offices Cleaning of Bathrooms Cleaning of Common/ Recreation Areas Cleaning of Kitchens Cleaning of Dining Areas Cleaning of Bedrooms Cleaning of Other Areas Cleaning of Linens

Please describe your procedure for Cleaning of Offices (including frequency); *

You may upload a copy of your Cleaning of Offices policy;

Please describe your procedure for Cleaning of Bathrooms (including frequency); *

You may upload a copy of your Cleaning of Bathrooms policy;

Please describe your procedure for Cleaning of Common/Recreation Areas (including frequency); *

You may upload a copy of your Cleaning of Common/Recreation Areas policy (including frequency);

Please describe your procedure for Cleaning of Kitchens (including frequency); *

You may upload a copy of your Cleaning of Kitchens policy;

Please describe your procedure for Dining Areas (including frequency); *

You may upload a copy of your Cleaning of Dining Areas policy;

Please describe your procedure for Cleaning of Bedrooms (including frequency); *

You may upload a copy of your Cleaning of Bedrooms policy;

Please describe your procedure for Cleaning of Other Areas (including frequency); *

You may upload a copy of your Cleaning of Other Areas policy;

Please describe your procedure for Cleaning of Linens; *

You may upload a copy of your Cleaning of Linens policy;

Any additional notes/information;