Based on the Centers for Disease Control and Prevention (CDC) Environmental Checklist for Monitoring Terminal Cleaning, this terminal cleaning checklist aims to help hospital housekeeping officers indicate “cleaned”, “not cleaned”, or “not present in room” when cleaning high-touch room surfaces and specify the monitoring method used.
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Title Page
Healthcare Facility
Address
Hospital Housekeeping Officer
Conducted on
Terminal Cleaning Checklist
Unit
Room Number
High-touch Room Surfaces
Bed rails / controls
Tray table
IV pole (grab area)
Call box / button
Telephone
Bedside table handle
Chair
Room sink
Room light switch
Room inner door knob
Bathroom inner door knob / plate
Bathroom light switch
Bathroom handrails by toilet
Bathroom sink
Toilet seat
Toilet flush handle
Toilet bedpan cleaner
IV pump control
Multi-module monitor controls
Multi-module monitor touch screen
Multi-module monitor cables
Ventilator control panel
Sign Off
Monitoring Method Used:
Additional Comments
Hospital Housekeeper Name & Signature
Hospital Housekeeping Officer Name & Signature
SafetyCulture Staff
Terminal Cleaning Checklist
Based on the Centers for Disease Control and Prevention (CDC) Environmental Checklist for Monitoring Terminal Cleaning, this terminal cleaning checklist aims to help hospital housekeeping officers indicate “cleaned”, “not cleaned”, or “not present in room” when cleaning high-touch room surfaces and specify the monitoring method used.
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.
