Title Page
-
Division/Location
-
Conducted on
-
Prepared by
WAITING ROOM:
-
Location:
-
Overall condition of the waiting room cleaned?
RESTROOM:
Restroom:
-
Location:
-
1. Toilet bowl / Plumbing fixtures clean?
-
2. Sink / Plumbing fixtures clean?
-
3. Mirriors clean?
-
4. Walls / Stalls clean?
-
5. Wastecans clean & freshly lined?
-
6. Floors clean / mopped?
-
7. Vents / Cieling clean?
-
8. Supplies in place?
Restroom:
-
Location:
-
1. Toilet bowl / Plumbing fixtures clean?
-
2. Sink / Plumbing fixtures clean?
-
3. Mirriors clean?
-
4. Walls / Stalls clean?
-
5. Wastecans clean & freshly lined?
-
6. Floors clean / mopped?
-
7. Vents / Cieling clean?
-
8. Supplies in place?
ANCILLARY AREAS:
Area:
-
Location:
-
1. Cabinets Cleaned?
-
2. Counters Cleaned?
-
3. Sinks Cleaned?
-
4. Walls Cleaned?
-
5. Ceiling Cleaned?
-
6. Ledges Cleaned?
-
7. Vents Cleaned?
-
8. Wastecans Cleaned & Freshly Lined?
-
9. Supplies in Place?
-
10. Floors Cleaned?
-
11. Exam Table (Foot Stool)
-
12. Cubical Curtains (Changed)
Area:
-
Location:
-
1. Cabinets Cleaned?
-
2. Counters Cleaned?
-
3. Sinks Cleaned?
-
4. Walls Cleaned?
-
5. Ceiling Cleaned?
-
6. Ledges Cleaned?
-
7. Vents Cleaned?
-
8. Wastecans Cleaned & Freshly Lined?
-
9. Supplies in Place?
-
10. Floors Cleaned?
-
11. Exam Table (Foot Stool)
-
12. Cubical Curtains (Changed)
Area:
-
Location:
-
1. Cabinets Cleaned?
-
2. Counters Cleaned?
-
3. Sinks Cleaned?
-
4. Walls Cleaned?
-
5. Ceiling Cleaned?
-
6. Ledges Cleaned?
-
7. Vents Cleaned?
-
8. Wastecans Cleaned & Freshly Lined?
-
9. Supplies in Place?
-
10. Floors Cleaned?
-
11. Exam Table (Foot Stool)
-
12. Cubical Curtains (Changed)
Area:
-
Location:
-
1. Cabinets Cleaned?
-
2. Counters Cleaned?
-
3. Sinks Cleaned?
-
4. Walls Cleaned?
-
5. Ceiling Cleaned?
-
6. Ledges Cleaned?
-
7. Vents Cleaned?
-
8. Wastecans Cleaned & Freshly Lined?
-
9. Supplies in Place?
-
10. Floors Cleaned?
-
11. Exam Table (Foot Stool)
-
12. Cubical Curtains (Changed)
FLOORCARE:
Floorcare:
-
Location:
-
1. Baseboard Cleaned?
-
2. Corners Cleaned?
-
3. Edges Cleaned?
-
4. Floors Finished / Carpet Clean?
Floorcare:
-
Location:
-
1. Baseboard Cleaned?
-
2. Corners Cleaned?
-
3. Edges Cleaned?
-
4. Floors Finished / Carpet Clean?
ENVIRONMENTAL ROUNDS:
Personal Protective Equipment
-
1. Gloves?
-
2. Eye Goggles?<br>
Chemical
-
1. Disinfection wipe container lids closed and labeled correctly?
-
2. Chemical Dispensing unit in working condition?
-
3. Disinfectant Wipe/bottle properly Dated?
Hopper Closet
-
1. Closet cleaned & organized?
-
2. Eye Wash Station Clean & Checked?
-
3. Work Charts Available?
-
4. Housekeeping Cart Clean & Orderly?
Stairwell/Elevator
-
Elevator Location:
-
1. Elevator Tracks / Door Clean?
-
Stairwell Location:
-
2. Stairwell Clean free of Dust/Litter?
-
3. Stairwell Ledges / Handrails Clean?