Title Page

  • Conducted on

  • Prepared by

  • Location

  • Specific location of audit

Hand Hygiene Observation

  • Designation of person completing hand hygiene

  • Name of person being audited

  • Did they perform hand hygiene? (If no, please provide the reason: hands full, frequent entry/exit, dispenser empty, improper glove use, or other

  • What method?

  • Did they spend 15-20 seconds washing their hands?<br>For alcohol based hand rub (ABHR) did they rub their hands together vigorously ensuring contact with all surfaces of hands and let dry?

  • Hand Hygiene Moment

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

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