Audit

Healthcare Worker 1
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 2
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 3
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 4
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 5
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 6
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays,no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 7
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 8
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlay, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 9
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Healthcare Worker 10
Which Healthcare Worker?

Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit,
Dispencer empty, Improper glove use, or Other

What method?

Did they spend 15-20 seconds washing their hands?

Entry or Exit?

Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

Confirm Date and Time and Signature

Date and Time Completed
By entering name, this acts as an electronic signature.
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.