Managers - Infection Prevention performed an inspection of your unit/facility. Please review your survey and document your Plan of Correction next to each deficiency.
Please return this form to me by:
Hand Hygiene

Sinks for hand hygiene are available in all areas as needed?

Specimens and/or infectious waste not disposed of into sinks designated for hand hygiene.

Soap and hand sanitizer dispensers are well stocked.

Specimen Collection Area

PPE available to staff and worn during specimen collection (lab coats buttoned, sleeves not pulled up, gloves over sleeves; masks/face shields worn for collection of nasal or oral specimen).

Sharps containers readily available for disposal of venipuncture needles.

Sharps containers not overfilled.

Specimen collection area is regularly cleaned.

No food or drinks stored in this area.

Alcohol hand rubs are available in patient draw rooms and well stocked.

Hand hygiene is performed between patients.

Patient Nutrition

Refrigerator clean and thawed of ice?

Patient refrigerator labeled for patient use only or patient food clearly separated from employee food if shared?

Temperature checks are documented daily with corrective action when temperature is out of range?

No expired food present?

Ice and/or water machine is clean?

Is this section free of additional findings?


Doors, floors, walls, workbenches, ceiling tiles, etc. clean.

Proper PPE is available and worn while specimens are handled.

No food, drinks, application of cosmetics or lip balm in work areas where specimens are present.

Clean supply shelves have a solid bottom shelf.

Expired supplies are not present.

Biohazard trash is segregated from regular trash.

Needles, syringes, pipette tips, other sharps are disposed of properly.

Infectious waste in red bag or container.

Dirty PPE is handled appropriately.

Nothing is stored under sinks (except for cleaning supplies) and there are no signs of leaks.

Restrooms are clean.

Trash baskets are not overflowing.

Is this section free of additional findings?

Biological Safety Cabinets (BSC)

BSC is currently certified for use and gauges checked before use.

Only materials and equipment needed for immediate work are stored in the BSC.

Appropriate PPE worn while working in the BSC (lab coats worn and buttoned, gloves pulled over the wrists of lab coats).

Manipulation of materials inside the cabinet delayed for 1 minute after placing hands/arms inside the cabinet to allow the air to stabilize and to "air sweep" arms.

Arms not resting on front grille unless BSC is specifically equipped with permitting features.

Front grille not blocked with papers or other materials.

All operations performed on work surface and at least 4 inches from front grille.

All equipment brought out of the BSC is surface decontaminated prior to removal.

Process established for regular cleaning of interior walls and window with 70 percent ethanol or other approved disinfectant.

Eyewash Station

Eyewash station located in areas that are accessible within 10 seconds (roughly 55 feet).

Eyewash stations located on the same level as the hazard and the path of travel is free from obstructions.

Eyewash station activated weekly for a period long enough to verify operation and ensure that flushing fluid is available.

Eyewash bottles are considered supplemental with main purpose to supply immediate flushing only (Injured individual would then proceed to a plumbed or self contained eyewash and flush for the required 15-minute period).

Dust caps or dust covers installed to protect the unit from contaminates.

Blood Bank

Blood product refrigerators and freezers clean.

No expired blood products present in inventory (red blood cells, platelets, plasma, cryoprecipitate, rhogam, etc.).

Fresh frozen plasma stored at 1-6 C no more than 24 hours.

Single units of thawed cryoprecipitate stored at room temperature no more than 6 hours.

Blood product thawing baths emptied and cleaned regularly.


Temperature logs complete for blood product storage (RBCs, Platelets, Plasma, Cryo)?

Equipment cleaning logs complete with corrective actions as needed?

High-level disinfection documentation

Sterilization documentation

Clean Utility / Central Supply / Storage

Walls / floors are clean and undamaged?

Air intake vents and diffusers are clean/free of dust

Ceiling tiles are not stained or wet.

Supplies are stored at least 6 inches off of the floor.

Clean supply cart has solid surface or plastic barrier on bottom shelf.

There are no outside cardboard shipping boxes present among clean supplies.

There are no expired supplies present.

Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks.

Is this section free of additional findings?

Soiled Linen / Dirty Utility Room

Door to soiled linen / dirty utility room locked?

Biohazard symbol on door of biomedical waste storage?

Ceiling tiles are not discolored/ wet/ missing / damaged?

Dust not found in high places?

Soiled materials are stored appropriately?

Is this section free of additional findings?

Employee Kitchen / Breakroom

Doors, floors, walls, counter tops clean?

Microwave oven clean?

Refrigerator clean and thawed of ice?

Temperature checks are checked/documented daily with corrective action when temperature is out of range?

No expired or old food found?

There is nothing stored under the sink (except for cleaning supplies) and there are no signs of leaks?

Is this section free of additional findings?

Employee General Knowledge and Competency

Personnel can locate PPE.

Personnel can locate the Infection Control Manual.

Employees know the procedure for blood exposure.

Personnel know procedure and have PPE available for cleaning up a body fluid spill.

Personnel can locate their chemical spill kit.

Personnel can demonstrate knowledge of and compliance with mandatory reporting requirements for reportable diseases.

Is this section free of additional findings?

Environmental Services

Facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.

Personnel who clean and disinfect patient care areas (e.g., environmental services, technicians, nurses) receive training on cleaning procedures: upon hire, annually, when new equipment or protocols are introduced.

Facility has a policy/procedure for decontamination of spills of blood or other body fluids.

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.