Title Page

  • Conducted on

  • Auditor

  • Unit

  • Please specify:


  • Role of person observed

  • Best guess:

  • Where is the observation?

  • Describe:

  • Which precautions should be applied for this patient/observation?

  • Was HH performed prior to donning PPE?

  • Was gown donned prior to gloves?

  • Are gloves applied correctly and covering the sleeve cuffs?

  • Are both gown ties tied behind the back?

  • Was the PPE doffed in the correct order?

  • Was HH performed after doffing PPE?

  • Was mask applied correctly, if required?

  • Was the correct eye protection applied for the observation, if required?

  • Are any universal precautions required as routine practice?

  • Is the person compliant with routine practices?

  • Were there any sources of potential contamination (i.e. phones, pagers etc.)?

  • Describe:

  • If HH was performed, was the duration at least 15 seconds?

  • Any HH misses?

  • Names of any staff not complying with PPE or HH requirements:

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