Name of Business: The Practice
Industry: Healthcare
Address: 380 South Oyster Bay Road, Hicksville NY 11801
Contact Information: Doweon Park
Owner/Manager of Business: Doweon Park
Human Resources Representative and Contact Information, if applicable: N/A


  • Physical Distancing. To ensure employees comply with physical distancing requirements, you agree that you will do the following: Yes
  • Ensure 6 ft. distance between personnel, unless safety or core function of the work activity requires a shorter distance Any time personnel are less than 6 ft. apart from one another, personnel must wear acceptable face coverings. Yes
  • Tightly confined spaces will be occupied by only one individual at a time, unless all occupants are wearing face coverings. If occupied by more than one person, will keep occupancy under 50% of maximum capacity. Yes
  • Post social distancing markers using tape or signs that denote 6 ft. of spacing in commonly used and other applicable areas on the site (e.g. clock in/out stations, health screening stations) Yes
  • Limit in-person gatherings as much as possible and use tele- or video-conferencing whenever possible. Yes
  • Essential in-person gatherings (e.g. meetings) should be held in open, well-ventilated spaces with appropriate social distancing among participants. Yes but not applicable
  • Establish designated areas for pick-ups and deliveries, limiting contact to the extent possible. Yes
  • List common situations that may not allow for 6 ft. of distance between individuals. Yes
  • What measures will you implement to ensure the safety of your employees in such situations? Follow the CDC guidelines
  • How you will manage engagement with customers and visitors on these requirements (as applicable)? Customers and visitors will wait in their vehicles until instructed to enter the building, it is mandatory that they will not enter without a face mask and myself as a healthcare practitioner will wear PPE (consisting of a face mask, gloves and personal PPE body protection). No patient will come into contact with another patient in the waiting room, hallway, lavatory or on exiting the premise, they will wait in their car until they are directed to enter the premise, they will be Covid-19 screened with a questionnaire and their temperature will be taken.


  • Protective Equipment. To ensure employees comply with protective equipment requirements, you agree that you will do the following. Yes
  • Employers must provide employees with an acceptable face covering at no-cost to the employee and have an adequate supply of coverings in case of replacement. Yes
  • What quantity of face coverings – and any other PPE – will you need to procure to ensure that you always have a sufficient supply on hand for employees and visitors? How will you procure these supplies? 200 face masks, 10 PPE washable lab coats, 200 pairs of gloves. Items will be purchased locally from CVS, Stewarts Pharmacy, Staples or online at Amazon.
  • Face coverings must be cleaned or replaced after use or when damaged or soiled, may not be shared, and should be properly stored or discarded. What policy will you implement to ensure that PPE is appropriately cleaned, stored, and/or discarded? Create a log to track each phase: cleaned, stored or discarded.
  • Limit the sharing of objects and discourage touching of shared surfaces; or, when in contact with shared objects or frequently touched areas, wear gloves (trade-appropriate or medical); or, sanitize or wash hands before and after contact. Yes
  • Hygiene and Cleaning. To ensure employees comply with hygiene and cleaning requirements, you agree that you will do the following: Yes
  • Adhere to hygiene and sanitation requirements from the Centers for Disease Control and Prevention (CDC) and Department of Health (DOH) and maintain cleaning logs on site that document date, time, and scope of cleaning. Yes
  • Who will be responsible for maintaining a cleaning log? Where will the log be kept? Doweon Park
  • Provide and maintain hand hygiene stations for personnel, including hand washing with soap, water, and paper towels, or an alcohol-based hand sanitizer containing 60% or more alcohol for areas where hand washing is not feasible. Yes
  • Where on the work location will you provide employees with access to the appropriate hand hygiene and/or sanitizing products and how will you promote good hand hygiene? In the convenient place to get an access to
  • Conduct regular cleaning and disinfection at least after every shift, daily, or more frequently as needed, and frequent cleaning and disinfection of shared objects (e.g. tools, machinery) and surfaces, as well as high transit areas, such as restrooms and common areas, must be completed. I will be in compliance and maintain a log to record such functions are carried out and completed.
  • What policies will you implement to ensure regular cleaning and disinfection of your worksite and any shared objects or materials, using products identified as effective against COVID-19? Will be in compliance and maintain a log to ensure functions are carried out and completed.
  • Communication. To ensure the business and its employees comply with communication requirements, you agree that you will do the following: Yes
  • Post signage throughout the site to remind personnel to adhere to proper hygiene, social distancing rules, appropriate use of PPE, and cleaning and disinfecting protocols. Yes
  • Establish a communication plan for employees, visitors, and customers with a consistent means to provide updated information. Yes
  • Maintain a continuous log of every person, including workers and visitors, who may have close contact with other individuals at the work site or area; excluding deliveries that are performed with appropriate PPE or through contactless means; excluding customers, who may be encouraged to provide contact information to be logged but are not mandated to do so. Yes
  • Which employee(s) will be in charge of maintaining a log of each person that enters the site (excluding customers and deliveries that are performed with appropriate PPE or through contactless means), and where will the log be kept? Doweon Park
  • If a worker tests positive for COVID-19, employer must immediately notify state and local health departments and cooperate with contact tracing efforts, including notification of potential contacts, such as workers or visitors who had close contact with the individual, while maintaining confidentiality required by state and federal law and regulations. Yes


  • Screening. To ensure the business and its employees comply with protective equipment requirements, you agree that you will do the following:
  • Implement mandatory health screening assessment (e.g. questionnaire, temperature check) before employees begin work each day and for essential visitors, asking about (1) COVID-19 symptoms in past 14 days, (2) positive COVID-19 test in past 14 days, and/or (3) close contact with confirmed or suspected COVID-19 case in past 14 days. Assessment responses must be reviewed every day and such review must be documented. Have forms to be completed to document the above assessment which will be filed in customer files. Yes
  • What type(s) of daily health and screening practices will you implement? Will the screening be done before employee gets to work or on site? Who will be responsible for performing them, and how will those individuals be trained? Doweon Park
  • If screening onsite, how much PPE will be required for the responsible parties carrying out the screening practices? How will you supply this PPE? Face mask and gloves will be required to conduct the screening. 100 face masks and 100 sets of gloves will be available for screening customers, they will be available on site at my expense, gowns and other PPE are not necessary for this process.
  • Contact tracing and disinfection of contaminated areas. To ensure the business and its employees comply with contact tracing and disinfection requirements, you agree that you will do the following: Yes
  • Have a plan for cleaning, disinfection, and contact tracing in the event of a positive case. Yes
  • In the case of an employee testing positive for COVID-19, how will you clean the applicable contaminated areas? What products identified as effective against COVID-19 will you need and how will you acquire them? Will use Ammonia Chloride wipes for surfaces such as: door knobs, counter tops, treatment tables, furniture, bathroom surfaces, equipment such as printers, telephones (but limited too) and other communal equipment surfaces. Ammonia Chloride kills 99.9% of Viruses and Bacteria such as: fungal, mold, mildew, HIV, HIB, Hepatitis B and C and the Flu Virus. I will purchase this product at Staples or Home Depot.


  • Please use this space to provide additional details about your business’s Safety Plan, including anything to address specific industry guidance. We as Acupuncturist are certified in The Clean Needle Technique “CNT”, issued by The Council of Colleges of Acupuncture and Oriental Medicine, which certifies us as healthcare provider to handle blood and body fluids (safely and cautiously with gloves, gowns, masks and eye protection) and also how depose them in (labeled bio-hazard containers). We are also certified in the protection of ourselves from possible contamination as well as from contaminating our patients or in cross contamination of contaminating other patients.
  • Staying up to date on industry-specific guidance: To ensure that you stay up to date on the guidance that is being issued by the State, you will:
  • Consult the NY Forward website at and applicable Executive Orders at orders on a periodic basis or whenever notified of the availability of new guidance. Yes
  • State and Federal Resources for Businesses and Entities, Yes
  • As these resources are frequently updated, please stay current on state and federal guidance issued in response to COVID-19. Yes I will comply.
  • General Information
  • New York State Department of Health (DOH) Novel Coronavirus (COVID-19) Website Centers for Disease Control and Prevention (CDC) Coronavirus (COVID-19) Website Occupational Safety and Health Administration (OSHA) COVID-19 Website. Yes I will current,
  • Workplace Guidance. Yes I will maintain a current status on the following Industry, State and Federal Guidelines.
  • CDC Guidance for Businesses and Employers to Plan, Prepare and Respond to Coronavirus Disease 2019. Yes I will stay current.
  • OSHA Guidance on Preparing Workplaces for COVID-19. Yes I will stay current.
  • Personal Protective Equipment Guidance. Yes I will stay current.
  • DOH Interim Guidance on Executive Order 202.16 Requiring Face Coverings for Public and Private Employees. Yes I will stay current.
  • OSHA Personal Protective Equipment. Yes I will stay current.
  • Cleaning and Disinfecting Guidance. Yes I will stay current.
  • New York State Department of Environmental Conservation (DEC) Registered Disinfectants of COVID-19 DOH Interim Guidance for Cleaning and Disinfection of Public and Private Facilities for COVID-19. Yes I stay current and following all guidelines.

Screening and Testing Guidance

DOH COVID-19 Testing

CDC COVID-19 Symptoms