Information

  • Conducted on

  • Prepared by

  • Personnel

OR #1

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #2

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #3

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #4

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #5

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #6

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #7

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #8

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #9

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #10

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #11

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #12

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #14

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #15

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR #16

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

OR GU Room

  • Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  • Procedure room furniture, metal tables, and carts are clean and dust free.

  • Procedural room lights are clean and dust free.

  • Procedure cart/bed is clean and free of dust, blood or body fluids.

  • Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  • The procedural floor is clean and free of soiling or blood and body fluids.

  • Procedural room trash and biohazardous waste has been removed and disposed of properly.

  • All soiled linen has been removed from procedural room.

  • Vents are free of dust and debris.

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.