Isolation Audit Tool

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Shift

  7a-3p

  3p-11p

  11p-7a

• HCW Type

  RN

  NA

  Physician

  PA/NP

  Other

• Isolation Type

  Contact

  Contact PLUS

  Droplet

  Airborne

Supplies

• Proper signage

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Gowns available

  Yes

  No

  N/A

• Masks available

  Yes

  No

  N/A

• Bleach wipes available for Contact PLUS

  Yes

  No

  N/A

• All supplies available

  Yes

  No

  N/A

PPE

• Compliant with gloves

  Yes

  No

  N/A

• Compliant with gowns

  Yes

  No

  N/A

• Compliant with mask

  Yes

  No

  N/A

• Compliant with all PPE

  Yes

  No

  N/A