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
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.