Title Page

  • Conducted on

  • Prepared by

  • Location
  • there are no environmental risks


  • instruments are opened at point of use

  • the bracket table is clean

  • hand hygiene is performed (5 moments)

  • instruments are gathered

  • everything is opened in an aseptic manner

  • blue wrap is present

  • non-touch technique is applied

Personal Protective Equipment

  • gown are worn (if high risk procedure)

  • mask are worn and fitted appropriately

  • glasses are worn and well fitted

  • 5 moments of hand hygiene is demonstrated

  • gloves are worn


  • hand hygiene (5 M/Gloves)

  • non-touch technique is demonstrated

  • needle are disposed appropriately after use

  • key parts are separated and protected on the bracket table

  • bracket table is uncluttered

Type of field is managed correctly

  • general aseptic field is managed correctly

  • critical aseptic field is managed correctly

  • surgical aseptic field is managed correctly (DSU)

  • Point of use wiping is managed correctly

  • sharps are disposed appropriately

  • waste is segregated and disposed appropriately

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.