Infection Prevention and Control Report

• Conducted on

  Date
• Location
  Address

Disclaimer 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

• Gloves

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Please choose which gloves are available

  Select Unsterile Sterile

  • Unsterile
  • Sterile

• Isolation Gown

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Face Shield / Goggles

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Surgical Mask

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• N95 Mask

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Please choose which N95 Mask is available

  Select 3M Cup 1860 Regular 3M Cup 1860S Small Kimberly Clark Regular Kimberly Clark Small 3M Molded 1805 Regular 3M Molded 1805S Small PAPR Hood Other

  • 3M Cup 1860 Regular
  • 3M Cup 1860S Small
  • Kimberly Clark Regular
  • Kimberly Clark Small
  • 3M Molded 1805 Regular
  • 3M Molded 1805S Small
  • PAPR Hood
  • Other

• If answer is other write down

Hand Hygiene

• Alcohol Based Hand Rub wall Dispensers filled up

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Alcohol Based Hand Rub Bottle available

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Soap Dispenser filled up

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Paper Towels available

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

Isolation Practices when applicable

• Negative Pressure Room Monitoring

  Yes

  No

  N/A

• Sign Precaution Hanged outside isolation room / or on curtain in case of cohorting

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• PPE kept outside isolation room / or beside bed in case of cohorting

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Isolation log book available

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

Medical Waste Segregation

• No overfilling observed

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• No mixing disposal

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• No recapped needles

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• All containers kept clean

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

Housekeeping

• Double Buckets for Regular room available

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Double Buckets for isolation room available

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Double Buckets Containers kept clean

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• 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)

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Is cleaning schedule available?

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

Environmental Disinfectant

• Spray Disinfectant available (Please write the name of Disinfectant in the note down)

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Floor Disinfectant available (Please write the name of Disinfectant in the note down)

  Select Yes No Not applicable Not available from Medical Store

  • Yes
  • No
  • Not applicable
  • Not available from Medical Store

• Write down any other remarks

• IPC Practitioner

  Sign

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

• Acknowledgment of receipt of the report