Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location


  • 1. Correct pressure relations. ( Negative to the hallways, positive in clean room)

  • 2. Temperature and Humidity Log filled out and within normal ranges.

  • 3. Door closed to hallway.

  • 4. Eye wash stations are checked on a weekly basis and documented.

  • 5. Floors are clean and free of clutter.

Decontamination Room

  • 1. Physical separation from the Clean Room.

  • 2. Separate sinks for washing instruments and for hygiene.

  • 3. PPE supplies present in decontamination room.

  • 4. Source of treated water present. (deionized, reverse osmosis, filtered)

  • 5. Cleaning Chemicals are not expired.

  • 6. Solution temp and soak time is monitored and documented.

  • 7. Pre-cleaning appears to be occurring before instruments are brought to decontamination.

  • 8. No "clean" items/equipment present in the decontamination room to prevent cross contamination.

PPE requirements

  • 1. A fluid resistant gown with sleeves is worn.

  • 2. Gloves, a mask and eye protection is worn.

  • 3. Shoe covers or boots designed for use as PPE being used.

  • 4. Hand hygiene performed after PPE is removed.

Clean Room

  • 1. Terminal Cleaning performed at the end of the day per policy.

  • 2. IFUs for sterilizers are being followed for operation and routine maintenance is being performed.

  • 3. Lot number and expiration date are being captured for the Bowie Dicks.

  • 4. Immediate use steam sterilization is being monitored.

  • 5. Test strips or indicators are dated correctly and labeled with expiration date.

Packaging and Storage

  • 1. All sterile peel packs are labeled with a sticker from CSR which identifies the load number and date that the peel pack was sterilized.


  • 1. All cylinders (oxygen, other compressed gas) are secured

  • 2. Fire extinguishers not obstructed from easy access

  • 3. No electrical panels are blocked

  • 4. hospital furnishings/equipment are kept in good repair

  • 5. Countertops/doors are in good condition with no chipping to laminate

  • 6. No supplies stored under sinks

  • 7. Paper is not present on fire-rated doors

  • 8. Maintains the integrity of egress throughout the unit

  • 9. No space heaters present

  • 10. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.