Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

  • Floors clean and in good repair

  • Ceiling tiles unstained.

  • Only allowable supplies stored under sinks.

  • No external shipping containers where clean/sterile supplies are present.

  • Sharps containers not more than 2/3 full

  • Hand Hygiene performed before and after room entry/exit.

  • Isolation signs posted appropriately

  • Isolation cart/supplies available

  • Staff wearing appropriate PPE

  • Proper disinfectant available

  • Shower hose hanging without loops (empty patient rooms)

  • Horizontal surfaces are clean

  • No visible soil on vertical surfaces

  • Hallways uncluttered

  • Clean linen covered

  • Solid bottom present on bottom supply storage shelf

  • Clean supplies separate from dirty

  • All supplies within expiration date

  • Reusable instruments sprayed/soaked in enzymatic solution

  • No instrument cleaning in hand-washing sinks

  • Soiled instruments transported in bio-hazard-labeled covered container

  • Supplies are at least 18 inches from ceiling and 6 inches from floor

  • Medications are within expiration date

  • Open, multi-dose vials are labeled with expiration date

  • High-Level Disinfection processes compliant


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  • Add media

Cart & Instrument Compliance

  • # of carts compliant ____<br># carts observed ____

  • # Instrument totes compliant _____<br># Instrument totes Observed _____

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.