ROSEVILLE EVS CLEANING CART INSPECTION OBSERVATION. TEMPLATE

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

CART OBSERVATIONS

• 1. Dusting tool present

  Yes

  No

  N/A

• 2. Wet mop handle and head is present and in good condition?

  Yes

  No

  N/A

• 3. CRT is organized according to cart set up card?

  Yes

  No

  N/A

• 4. cart is clean and presentable to the customers and caddy is clean?

  Yes

  No

  N/A

• 5. All products and buckets are labels properly with secondary labels?

  Yes

  No

  N/A

• 6. Wet floor sign/wet floor magnets (6) Re on cart?

  Yes

  No

  N/A

• 7. No personal items, Food or drinks and/or personal stickers are present?

  Yes

  No

  N/A

• 9. Dust pan and lobby broom is present and clean and emptied?

  Yes

  No

  N/A

• 10. Putty knife, small grout brush, white scrub pad present?

  Yes

  No

  N/A

CLEANING PRODUCTS

• 11. DFC Cleaner / Germicidal cleaner

  Yes

  No

  N/A

• 12. Pure Brite disinfectant/Bleach wipes

  Yes

  No

  N/A

• 13. Liquid abrasive cleaner

  Yes

  No

  N/A

• 14. Stainless Steel cleaner

  Yes

  No

  N/A

• 15. Gum off

  Yes

  No

  N/A

• 16.

  Yes

  No

  N/A

SUPPLIES STOCKED. EQUIPMENT/OTHER OBSERVATION

• 17. Hand washing soap. (4)

  Yes

  No

  N/A

• 18. Toilet paper (4)

  Yes

  No

  N/A

• 19. Plastic liners appropriate to area

  Yes

  No

  N/A

• 20. Microfiber mops (appropriate amount not over stocked)

  Yes

  No

  N/A

• 21. High touch laminated card present and other instruction cards?

  Yes

  No

  N/A

• 22. Seat covers (4)

  Yes

  No

  N/A

• 23. Paper Towels (2 - 4)

  Yes

  No

  N/A

• 24. Microfiber Towels (appropriate amount and not overstocked)

  Yes

  No

  N/A

• A25. EVS Service Cards / Tent cards <br>(Hospital only)

  Yes

  No

  N/A

(#YES & NA /27 ) x 100 / = % (Acceptable Cart is > 90% )

FOLLOW UP ACTION

• Individual teaching provided to employee. DATE

  Yes

  No

  N/A

• In service needed for the department DATE

  Yes

  No

  N/A

• EVS COMMUNICATION MEMO. DATE

  Yes

  No

  N/A

• Share at up coming Huddle. DATE

  Yes

  No

  N/A

• Review or revise policy and procedures. DATE

  Yes

  No

  N/A

• Add to EVS UBT agenda. DATE

  Yes

  No

  N/A

• Other comments.

  Yes

  No

  N/A