Title Page

  • Campus Location

  • Conducted on

  • Prepared by

  • Employee Name:

  • Room Location:

  • Date Marked:

  • Time Marked:

  • Cleaning Type

  • Date Inspected:

  • Time Inspected:

Yes = Completely Removed / No = Appeared Untouched

  • 1. Bathroom Light Switch

  • 2. Bed Pan Cleaner

  • 3. Bedside Table

  • 4. Call light/box (Including cord)

  • 5. Chairs in Room

  • 6. Room door knob/handle

  • 7. Side Rails

  • 8. Sink

  • 9. Telephone

  • 10. Bathroom door knob

  • 11. Bathroom hand hold

  • 12. Toilet handrail/handhold

  • 13. Toilet Seat

  • 14. Tray (over-bed) Table

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