Non-Patient Restroom HRO

• Location

• Conducted on

  Date

• Prepared by

• Employee Name:

• Restroom Location:

• Date Marked:

  Date

• Time Marked:

  Date

• Cleaning Type

  Daily

  Discharge

  N/A

• Date Inspected:

  Date

• Time Inspected:

  Date

Yes = Completely Removed / No = Appeared Untouched

• 1. Bathroom Light Switch

  Yes

  No

  N/A

• 2. Bathroom Door Handle

  Yes

  No

  N/A

• 3. Counter Top

  Yes

  No

  N/A

• 4. Faucet Handle

  Yes

  No

  N/A

• 5. Bathroom Handhold

  Yes

  No

  N/A

• 6. Baby Changing Station

  Yes

  No

  N/A

• 7. Stall Handle

  Yes

  No

  N/A

• 8. Toilet Plumbing

  Yes

  No

  N/A

• 9. Toilet Seat

  Yes

  No

  N/A

• 10. Auto Hand Dryer

  Yes

  No

  N/A