Employee Name:

Room Location:

Date Marked:
Time Marked:

Cleaning Type

Date Inspected:
Time Inspected:
Yes = Completely Removed / No = Appeared Untouched

1. Bathroom Light Switch

2. Bathroom Door Knobs

3. Toilet Faucet/handrail/handhold

4. Head Wall Control (Discharge Only)

5. Toilet Seat/ Porta Pottie

6. Handle / Glass door

7. Bedside Table/Cart/Tray (Discharge Only)

8. Exam light / Monitor (Discharge Only)

9. Telephone / Call light (Discharge Only)

10. Chair in room

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.