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?

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