IPC Survey Audit

• Conducted on

  Date

• Client / Site

• Location
  Address

• Prepared by

• Personnel

• Document No.

• Old Score

Disclaimer The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.

Confidentiality Statement In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.

Personal Protective Equipment (PPE) availability

• Gloves

  Yes

  No

  N/A

• Please choose which gloves are available

  Select Unsterile Sterile

  • Unsterile
  • Sterile

• Isolation Gown

  Yes

  No

  N/A

• Face Shield / Goggles

  Yes

  No

  N/A

• Surgical Mask

  Yes

  No

  N/A

• N95 Mask

  Yes

  No

  N/A

• Please choose which N95 Mask is available

  Select 3M Cup 1860 Regular 3M Cup 1860S Small Kimberly Clark Regular Kimberly Clark Small 3M Molded 1805 Regular 3M Molded 1805S Small

  • 3M Cup 1860 Regular
  • 3M Cup 1860S Small
  • Kimberly Clark Regular
  • Kimberly Clark Small
  • 3M Molded 1805 Regular
  • 3M Molded 1805S Small

Hand Hygiene Program

• Alcohol Based Hand Rub Dispensers filled up

  Yes

  No

  N/A

• Alcohol Based Hand Rub Bottle available

  Yes

  No

  N/A

• Soap Dispenser filled up

  Yes

  No

  N/A

• Paper Towels available

  Yes

  No

  N/A

Isolation Practices

• Sign Precaution Hanged outside isolation room / or on curtain in case of cohorting

  Yes

  No

  N/A

• PPE kept outside isolation room / or beside bed in case of cohorting

  Yes

  No

  N/A

• Staff Compliance to Standard Precaution Practices

  Yes

  No

  N/A

• Isolation log book available

  Yes

  No

  N/A

Medical Waste Segregation

• No overfilling observed

  Yes

  No

  N/A

• No mixing disposal

  Yes

  No

  N/A

• No recapped needles

  Yes

  No

  N/A

• All containers kept clean

  Yes

  No

  N/A

Housekeeping

• Double Buckets for Regular room available

  Yes

  No

  N/A

• Double Buckets for isolation room available

  Yes

  No

  N/A

• Double Buckets Containers kept clean

  Yes

  No

  N/A

• Is the area kept clean and no visible soil or dirt all horizontal and vertical surfaces (Please explain in the note down in case if non-compliant)

  Yes

  No

  N/A

• Is cleaning schedule available?

  Yes

  No

  N/A

Environmental Disinfectant

• Spray Disinfectant available (Please write the name of Disinfectant in the note down)

  Yes

  No

  N/A

• Floor Disinfectant available (Please write the name of Disinfectant in the note down)

  Yes

  No

  N/A

• Name of Audit Surveyor

  Sign