Hand Hygiene Observation Tool

• Unit/Floor

  Select

• Conducted on

  Date

• Observed by

  Select

Healthcare Worker 1

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 2

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 3

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 4

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 5

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 6

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 7

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 8

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 9

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A
Healthcare Worker 10

• Hour of Observation.

  Select 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600

  • 0700
  • 0800
  • 0900
  • 1000
  • 1100
  • 1200
  • 1300
  • 1400
  • 1500
  • 1600

• Which Healthcare Worker?

  Select RN NA MD RT PT Diet Lab HSK SW Pharm Rad

  • RN
  • NA
  • MD
  • RT
  • PT
  • Diet
  • Lab
  • HSK
  • SW
  • Pharm
  • Rad

• Entry or Exit?

  Entry

  Exit

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

  Yes

  No

• Dispenser Empty?

  Yes

  No

  N/A

• Hands Full?

  Yes

  No

  N/A

• Improper use of gloves?

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Confirm Date and Time and Signature

• Date and Time Completed

  Date

• By entering name, this acts as an electronic signature.

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