The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made.
Confidentiality Statement

In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.


Personal Protective Equipment (PPE) availability
Please choose which gloves are available
Isolation Gown
Face Shield / Goggles
Surgical Mask
N95 Mask
Please choose which N95 Mask is available

If answer is other write down

Hand Hygiene
Alcohol Based Hand Rub wall Dispensers filled up
Alcohol Based Hand Rub Bottle available
Soap Dispenser filled up
Paper Towels available
Isolation Practices when applicable

Negative Pressure Room Monitoring

Sign Precaution Hanged outside isolation room / or on curtain in case of cohorting
PPE kept outside isolation room / or beside bed in case of cohorting
Isolation log book available
Medical Waste Segregation
No overfilling observed
No mixing disposal
No recapped needles
All containers kept clean
Double Buckets for Regular room available
Double Buckets for isolation room available
Double Buckets Containers kept clean
Is the area kept clean and no visible soil or dirt all horizontal and vertical surfaces (Please explain in the note down in case if non-compliant)
Is cleaning schedule available?
Environmental Disinfectant
Spray Disinfectant available (Please write the name of Disinfectant in the note down)
Floor Disinfectant available (Please write the name of Disinfectant in the note down)

Write down any other remarks

IPC Practitioner
This section is approval of receiving a copy of the evaluation for the department that has been evaluated

Acknowledgment of receipt of the report

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.