• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.

  • Return this form to me by:

Summary of Survey

  • Score - Total Survey Score %

Employee Hand Hygiene Compliance

  • Employees Monitored

1.0 Supply Storage Areas

  • 1.1. Supply bens clean and dust free?

  • 1.2. Storage less than 18 inches from ceiling?

  • 1.3. Storage for supplies are appropriate?

  • 1.4. Boxes are off the floor?

  • 1.5. Package integrity of supplies are intact?

  • 1.6. Supply area is free of food and/or drink?

2.0. Personal Protective Equipment

  • 2.1. PPE cabinets (barrier boxes) are fully stocked?

  • 2.2. PPE removed prior to leaving area?

3.0 General Unit

  • 3.1. Ceiling tiles are not stained or wet?

  • 3.2. Air intake vents and diffusers are clean?

  • 3.3. Walls / floors are clean

  • 3.4. Unit / area generally clean (without dust, clutter or debris)?

  • 3.5. Expired supplies are not present?

  • 3.6. Appropriate soap/foam in use?

4.0. Employee General Knowledge

  • 4.1. Employees know where to find infection prevention policies?

  • 4.2. Employees know post-exposure protocol?

  • 4.3. Employees know how to document hand hygiene observations?

Additional Comments

  • Additional Comments

  • Surveyor's Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.