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