• 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. General Unit

  • 1.1. Ceiling tiles are not stained or wet?

  • 1.2. Air intake vents and diffusers are clean?

  • 1.3. Storage less than 18 inches from ceiling?

  • 1.4. Walls / floors are clean?

  • 1.5. Boxes are off the floor?

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

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

  • 1.8. Evidence of proper hand hygiene?

  • 1.9. Appropriate soap/foam in use?

2.0. Employee General Knowledge

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

  • 2.2. Employees know post-exposure protocol?

  • 2.3. 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.