LAS Breakroom Action Team Form
**DO NOT SUBMIT SSI IN TEXTBOXES**
** If you are not part of the Breakroom Action Team, please do not fill out this form! **
Name
*
First Name
Last Name
Location
*
Please Select
AB Checkpoint
Cx Checkpoint
D Checkpoint
T3 Checkpoint
CMF
Node 3
Node 4
Node 5a
Node 7
Node 8
Restocking
Restock Paper Towels
Yes
No
Other
Restock Alcohol
Yes
No
Other
Are any other supplies needed for future cleanings?
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Cleaning
Refrigerators
Dust the tops of refrigerators
Clear out expired items
Wipe down and disinfect refrigerator
Deep clean inside of refrigerator
Ensure the refrigerator works
Microwaves
Dust the tops of microwaves
Wipe down and disinfect microwaves
Ensure microwave works
Sinks
Wipe down and disinfect sinks
Ensure garbage disposal works
Ensure sinks works
Other Cleaning
Wipe down tables
Wipe down chairs
Dust tops of lockers
Clear out unnecessary clutter
Did you notify logistics about any damaged chairs, door handles, malfunction refrigerators, or non-operational microwaves? (Scan QR Code)
Yes
No
N/A
Other
Notes (if any steps were not taken, please write the reason here)
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Other/Logistics
Were there any decorations that needed cleaning
No
Yes (Notified designated person(s) to take them down)
Yes (Unable to notify designated person(s))
Other
Submit
Should be Empty: