Title Page

  • Conducted on

  • Prepared by

  • Location


  • Proper PPE use (gloves, mask, gown, etc)?

  • Personal Hygiene no artificial nails, hair pulled back, jewelry appropriate)?

  • STAFF KNOWLEDGE CHECK-What is the process if BBP exposure (splash, needlestick) occurs? (1-STIX/OHS)?


  • Review Isolation list/Possible SSI's with charge RN or Resource RN

  • Isolation Signage/PPE/MD order in EPIC align and correctly applied?

  • Staff wearing PPE? (tally mark if multiple observations done)

  • How many observations performed while in unit?

  • Families and visitors wearing appropriate isolation PPE?

  • STAFF KNOWLEDGE CHECK: Ambulating patient on isolation?

  • STAFF KNOWLEDGE CHECK: Family/visitor PPE requirements?


  • Conduct one visual bundle round (CLABSI, CAUTI, Ventilator, SSI)


  • 1 Hand Hygiene Observation

  • 1 Hand Hygiene Coaching


  • CLEAN and DIRTY items clearly separated?

  • NO food or drink outside of approved designated areas; hydration stations identified and utilized?

  • Nutrition room has labeled, non-expired foods in the refrigerator?

  • Nutrition room has no staff or family food stored in refrigerator?<br>

  • Human milk room has appropriate PPE and disinfectant wipes available for use?

  • Staff using PPE and disinfectants appropriately while entering/exiting human milk room?

  • Soiled Utility Room check (waste stream, soiled instrument process)?

  • STAFF KNOWLEDGE CHECK-How do you know this equipment has been cleaned and it is safe to use?

  • STAFF KNOWLEDGE CHECK-How often do you clean high touch areas?

  • STAFF KNOWLEDGE CHECK-Can staff identify high touch areas?

  • STAFF KNOWLEDGE CHECK-Contact time Purple Sani-wipes (2 min) and Clorox bleach disinfectant wipes (3 min)?


  • Patient Room

  • Room #
  • Isolation Room?

  • Swab #/Location

  • Location
  • RUL?

  • Re-test RUL?


  • Add media

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.