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 (Discharge Only)

4. Call light/box (Including cord) (Discharge Only)

5. Chairs in Room

6. Room door knob/handle

7. Side Rails (Discharge Only)

8. Sink

9. Telephone (Discharge Only)

10. Bathroom door knob

11. Bathroom hand hold

12. Toilet handrail/handhold

13. Toilet Seat

14. Tray (over-bed) Table (Discharge Only)

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.