Template Information
Hospital and ambulatory infection prevention site visit
Category: general
Template Questions
- Return this form to me by: Date
- Employee Hand Hygiene Compliance
- Name of observer and/or safety coach?
- I. Waiting Area
- II. Hand Hygiene
- III. Clean Utility / Central Supply / Storage
- IV. Soiled Linen / Dirty Utility Room
- V. Patient Rooms
- VI. Patient Kitchen / Nutrition Area
- VII. Employee Kitchen / Breakroom
- VIII. Nurses Station / Medication Room
- IX. Logs
- X. Isolation Rooms
- XI. Patient Shower Room
- XII. Environmental Services
- XIII. Employee General Knowledge and Competency
- Additional Comments
- Surveyor's Signature