Infection Control Surveillance - Registration

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.

• Return this form to me by:

  Date

Summary of Survey

• Score - Total Survey Score %

Employee Hand Hygiene Compliance

• Employees Monitored

1.0. General Unit

• 1.1. Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 1.2. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 1.3. Storage less than 18 inches from ceiling?

  Yes

  No

  N/A

• 1.4. Walls / floors are clean?

  Yes

  No

  N/A

• 1.5. Boxes are off the floor?

  Yes

  No

  N/A

• 1.6. Unit / area generally clean (without dust, clutter or debris)?

  Yes

  No

  N/A

• 1.7. Supply area is free of food and/or drink?

  Yes

  No

  N/A

• 1.8. Evidence of proper hand hygiene?

  Yes

  No

  N/A

• 1.9. Appropriate soap/foam in use?

  Yes

  No

  N/A

2.0. Employee General Knowledge

• 2.1. Employees know where to find infection prevention policies?

  Yes

  No

  N/A

• 2.2. Employees know post-exposure protocol?

  Yes

  No

  N/A

• 2.3. Employees know how to document hand hygiene observations?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign