OHIMO

• Campus

• Department/Area

• Conducted on

  Date

• Prepared by

Ice Machine Information

• Machine Location

• Serial Number

• Due Date Sticker

  Yes

  No

• If Yes, Date on Sticker:

• Black or Pink/Orange Mold present?

  Yes

  No

• If yes, location of mold:

• Is tray under ice spout clean?

  Yes

  No

• If no, explain:

• Does the water spout appear clean?

  Yes

  No

• If no, explain:

• Is calcification, color coating present on spout?

  Yes

  No

• If yes, explain:

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No

Usage Observation

• Person Using Machine

  Select Nutrition Visitor Patient Physician/NP RN PSA PT/OT Resp. Therapist Other (Please Specify)

  • Nutrition
  • Visitor
  • Patient
  • Physician/NP
  • RN
  • PSA
  • PT/OT
  • Resp. Therapist
  • Other (Please Specify)

• Specify "Other" Role:

• Container Type

  Select Pt. Ice Bag Pt. Water Pitcher Polar Pack Graduate Cylinder Staff Drinking Cup Visitor Drinking Cup Other (Specify Below)

  • Pt. Ice Bag
  • Pt. Water Pitcher
  • Polar Pack
  • Graduate Cylinder
  • Staff Drinking Cup
  • Visitor Drinking Cup
  • Other (Specify Below)

• Specify "Other" Type:

• Container Condition

  Used Item

  Unused Item

  Unknown

• Dumping Contents into Ice Machine Drain

  Yes

  No