Non - Patient E.Q.E.

• Division/Location

• Conducted on

  Date

• Prepared by

Public Restroom: 1

• Location:

• 1. Toilet bowl / Plumbing fixtures clean?

  Yes

  No

  N/A

• 2. Sink / Plumbing fixtures clean?

  Yes

  No

  N/A

• 3. Mirriors clean?

  Yes

  No

  N/A

• 4. Walls / Stalls clean?

  Yes

  No

  N/A

• 5. Wastecans clean & freshly lined?

  Yes

  No

  N/A

• 6. Floors clean / mopped?

  Yes

  No

  N/A

• 7. Vents / Cieling clean?

  Yes

  No

  N/A

• 8. Supplies in place?

  Yes

  No

  N/A

Public Restroom: 2

• Location:

• 1. Toilet bowl / Plumbing fixtures clean?

  Yes

  No

  N/A

• 2. Sink / Plumbing fixtures clean?

  Yes

  No

  N/A

• 3. Mirriors clean?

  Yes

  No

  N/A

• 4. Walls / Stalls clean?

  Yes

  No

  N/A

• 5. Wastecans clean & freshly lined?

  Yes

  No

  N/A

• 6. Floors clean / mopped?

  Yes

  No

  N/A

• 7. Vents / Cieling clean?

  Yes

  No

  N/A

• 8. Supplies in place?

  Yes

  No

  N/A

WAITING ROOM:

• Location:

• Overall condition of the waiting room cleaned?

  Yes

  No

  N/A

ANCILLARY AREA:

Ancillary Area: 1

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

Ancillary Area: 2

• Location:

• 1. Cabinets Cleaned?

  Yes

  No

  N/A

• 2. Counters Cleaned?

  Yes

  No

  N/A

• 3. Sinks Cleaned?

  Yes

  No

  N/A

• 4. Walls Cleaned?

  Yes

  No

  N/A

• 5. Ceiling Cleaned?

  Yes

  No

  N/A

• 6. Ledges Cleaned?

  Yes

  No

  N/A

• 7. Vents Cleaned?

  Yes

  No

  N/A

• 8. Wastecans Cleaned & Freshly Lined?

  Yes

  No

  N/A

• 9. Supplies in Place?

  Yes

  No

  N/A

• 10. Floors Cleaned?

  Yes

  No

  N/A

FLOORCARE:

Floorcare: 1

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

Floorcare: 2

• Location:

• 1. Baseboard Cleaned?

  Yes

  No

  N/A

• 2. Corners Cleaned?

  Yes

  No

  N/A

• 3. Edges Cleaned?

  Yes

  No

  N/A

• 4. Floors Finished / Carpet Clean?

  Yes

  No

  N/A

ENVIRONMENTAL ROUNDS:

Personal Protective Equipment

• 1. Gloves?

  Yes

  No

  N/A

• 2. Eye Goggles?<br>

  Yes

  No

  N/A

Chemical

• 1. Disinfection wipe container lids closed and labeled correctly?

  Yes

  No

  N/A

• 2. Chemical Dispensing unit in working condition?

  Yes

  No

  N/A

• 3. Disinfectant Wipe/bottle properly Dated?

  Yes

  No

  N/A

Hopper Closet

• 1. Closet cleaned & organized?

  Yes

  No

  N/A

• 2. Eye Wash Station Clean & Checked?

  Yes

  No

  N/A

• 3. Work Charts Available?

  Yes

  No

  N/A

• 4. Housekeeping Cart Clean & Orderly?

  Yes

  No

  N/A

Stairwell/Elevator

• Location:

• 1. Elevator Tracks / Door Clean?

  Yes

  No

  N/A

• Location

• 2. Stairwell Clean free of Dust/Litter?

  Yes

  No

  N/A

• 3. Stairwell Ledges / Handrails Clean?

  Yes

  No

  N/A