Title Page
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Site conducted
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Employee Name
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EID #
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Location
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Observed by
Validation occurs when the employee can perform the skill safely, correctly an legally with minimal coaching. Any skill or competency that does not apply to the specific service area, can be marked with "N/A"
Hand Hygiene/Glove Removal
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Date
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Describes appropriate hand hygiene technique and opportunities
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Engages in social motivation tactic to ensure proper hand hygiene
Patient Relations/Service Approach
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Date & Time
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Demonstrates a friendly/service approach
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Uses ISIT correctly
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Waits for permission to enter room
Cleaning Practices
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Date
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Prepares and uses chemicals according to policy
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Demonstrates correct and consistent process of cleaning an occupied room
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Demonstrates correct and consistent process of cleaning a restroom
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Demonstrates correct and consistent process of cleaning a discharge room
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Demonstrates correct and consistent process of cleaning an extra area
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Stocks linen according to job description for the designated areas
Isolation Room Cleaning Contact Isolation non C-Diff
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for contact Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with contact precautions
Isolation Room Cleaning Contact Isolation C-Diff
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for contact Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with contact precautions
Isolation Room Cleaning Droplet Isolation
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for Droplet Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact Droplet precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with Droplet precautions
Isolation Room Cleaning Airborne Isolation
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for Airborne Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact Airborne precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with Airborne precautions
Waste and Dirty Linen Processing
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Date
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Demonstrates the proper use of PPE work with waste and dirty linen
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Demonstrates the disposal of sharps container according to policy
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Demonstrates the disposal of Chemo waste container according to policy
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Demonstrates the disposal of black medical waste container according to policy
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Demonstrates the disposal of solid waste according to policy
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Demonstrates the disposal of Bio-Hazard waste
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Demonstrates the proper process of dirty linen
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Demonstrates the proper process for aluminum, newspaper, magazine, and plastic recycling
Fire Safety
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Date
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Can verbalize RACE & PASS
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Identifies the location of the fire pulls & verbalizes how to use the pull
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Identifies the location of the fire exits and fire extinguishers
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Prevent the blocking of any safety equipment: doors, fire pull or extinguishers
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Identifies the use of 9-911
Pager and Computer Use
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Date
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Access One Chart and performs task in program accurately (start & end shift, complete rooms and leave notes)
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Can access and enter information into the Work Order System
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Responds to the pager in an appropriate and timely way
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Demonstrate successfully the practice of using the pager to "page" someone
Equipment
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Date
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Can demonstrate the completion of the needed form to start the repair process
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Access the accessories as needed for the successful operation of the equipment for the job
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Demonstrates successful operation of the equipment and the weekly maintenance of the equipment
I verify this employee has met the ongoing competencies identified for their position
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General Comments
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Manager/Reviewer E-Signature
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Date Signed
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Employee E-Signature
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Date Signed
