Enter Date & Time

Proper hand washing observed.

Staff only wash hands in handwash sink.

Employees wear appropriate uniform including proper shoes.

Hair restraints worn (caps, hair nets, etc.).

Fingernails trimmed and kept clean.

Jewelry is restricted.

Glove use policy followed.

Open sores, cuts, or bandages completely covered.

Eating, drinking or chewing gum restricted to designated areas.

Staff take appropriate action when coughing or sneezing.


Hand wash stations available & stocked with anti-microbial hand soap, hand sanitizer and single-use towels?

Hand Washing signage displayed.

Sanitizing solution available in critical areas.


Employee Name & Signature.
Supervisor Name & 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.