Title Page
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Site conducted
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Employee Name
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EID #
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Location
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Observed by
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Date
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"
PATIENT RELATIONS/SERVICE APPROACH
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Date
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Demonstrates a friendly/service approach
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Uses ISIT correctly
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Waits for permission to enter room
HAND HYGIENE/GLOVE REMOVAL
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Date
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Describes appropriate hand hygiene technique and opportunities
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Engages in social motivation tactic to ensure proper hand hygiene
CLEANING PRACTICES
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Date
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Prepares and uses chemicals according to policy
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Demonstrates correct and consistent process utilizing pattern
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Demonstrates correct and consistent process of disinfecting the ceiling, proper pattern and process
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Demonstrates correct and consistent process of cleaning all equipment
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Demonstrates correct and consistent process of cleaning walls with proper equipment and pattern
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Demonstrates correct and consistent process when cleaning the floor
WASTE & DIRTY LINEN
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Date
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Demonstrates the proper use of PPE work with waste and dirty linen
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Demonstrates the disposal of sharps container according to policy
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Demonstrates the disposal of Chemo waste container according to policy
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Demonstrates the disposal of black medical waste container according to policy
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Demonstrates the disposal of solid waste according to policy
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Demonstrates the disposal of Bio-Hazard waste
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Demonstrates the proper processing of dirty linen
DOCUMENTATION
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Date
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Completes documentation of the cleaning process and is consistent
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Verbalizes the ability to communicate issues to the Management Team
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Successfully completed post test (85% as DAZO requires)
Employee E-Signatures & Verification
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Employee E-Signature
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Date
I verify this employee has met the ongoing competencies identified for their position this year.
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General Comments
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Manager's E-signature
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Date
