OR Room #

1. Operating table clean?

2. Surgical lights clean?

3. Phone clean?

4. Door / handle clean?

5. Light switch clean?

6. Omnicell clean?

7. Walls clean?

8. Ceiling clean?

9. Waste can clean?

10. Ledges free of dust?

11. Vents free of dust?

12. Flat surface tables clean?

13. Mayo stand clean?

14. Ring stand clean?

15. IV Pole clean? (Without mechanical device)

16. Step stools clean?

17. Chairs clean?

18. Floors clean?


1. Counters Cleaned?

2. Sink Cleaned?

3. Walls Cleaned?

4. Doors Cleaned?

5. Ceiling Cleaned?

6. Supplies In Place?

7. Floors Cleaned?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.