Title Page

  • Site conducted

  • Employee Name

  • EID #

  • Location

  • 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

  • Date

  • Describes appropriate hand hygiene technique and opportunities

  • Engages in social motivation tactic to ensure proper hand hygiene

Patient Relations/Service Approach

  • Date & Time

  • Demonstrates a friendly/service approach

  • Demonstrates a positive attitude toward customers

Linen Distribution Practices

  • Date

  • Counts and uses ControlTex according to policy

  • Can place a daily linen order with ControlTex/HESI

  • Demonstrates correct and consistent process of counting linens in stock & documenting (iPad)

  • Replenishes linen in a neat and orderly way

  • Fills carts with established pars according to ControlTex

  • Uses safety guidelines when transporting linen (covered/safely stacked)

  • Pushes/pulls Metro Carts only with a partner

  • Uses time productively

Pager/Telephone Use

  • Date

  • Carries pager(s) as assigned

  • Responds to the pager in an appropriate and timely way

  • Answers the telephone with Name, department, and "How can I help you" with a positive attitude

  • Can retrieve messages from the telephone when the red light is flashing

  • Leaves communications fro other staff in writing or verbally as needed


  • Date

  • Sorts and stocks scrubs in the Linen area

  • Stocks scrub cart an organized way

  • Evaluates daily scrub needs and communicates those needs, to place accurate scrub orders

  • Fills ScrubEx machines accurately and makes deliveries on time

  • Completes the filling process using the correct loader board functions

  • Can complete limited trouble shooting for issues and begin the repair process

  • Can access the IPA Clearview website, assist with staff questions and acquire accurate machine stock levels

Fire Safety

  • Date

  • Can verbalize RACE & PASS

  • Identifies the location of the fire pulls & verbalizes how to use the pull

  • Identifies the location of oxygen shut off valves and verbalized how to shut them off.

  • Identifies the location of the fire exits and fire extinguishers

  • Prevent the blocking of any safety equipment: doors, fire pull or extinguishers

  • Identifies the use of 9-911

Washer & Dryer Use (in environmental services)

  • Date

  • Accurately fills the washer with product and sets cycles

  • Accurately fills the dryer with product and sets the correct temperatures

  • Can verbalize and follow through with patient clothing cleaning process (paper work, storage, follow up)

  • Unpack and process the products in the blue bins

  • Accurately document on all the tracking forms

  • Monitors and changes the chemicals as needed & communicates needs

Waste and Dirty Linen Processing

  • Date

  • Demonstrates the proper use of PPE work with waste and dirty linen

  • Demonstrates the disposal of solid waste according to policy

  • Demonstrates the proper process of dirty linen

  • Demonstrates the proper process for aluminum, newspaper, magazine, and plastic recycling


  • Date

  • Can demonstrate the completion of the needed form to start the repair process

  • Access the accessories as needed for the successful operation of the equipment for the job

I verify this employee has met the ongoing competencies identified for their position

  • General Comments

  • Manager/Reviewer E-Signature

  • Date Signed

  • Employee E-Signature

  • Date Signed

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.