HEALTHCARE INFECTION CONTROL CHECKLIST: PREVENTION & PROTOCOL

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--- HAND HYGIENE COMPLIANCE ---
[ ] Last Hand Hygiene Time
[ ] Hand Hygiene Method (Soap & Water, Alcohol-Based Hand Rub)
[ ] Duration of Handwashing (seconds)
[ ] Areas Touched During Hand Hygiene (Fingertips, Palms, Backs of Hands, Between Fingers, Wrists)
[ ] Observation Notes (if applicable) (Compliant, Needs Improvement, Not Observed)
[ ] Observer Signature

--- PERSONAL PROTECTIVE EQUIPMENT (PPE) USAGE ---
[ ] Type of PPE Used (e.g., Gloves, Gown, Mask, Eye Protection) (Gloves, Gown, Mask, Eye Protection, Full Face Shield)
[ ] Correct Glove Size Selected? (Yes, No, N/A)
[ ] Number of Masks/Respirators Available
[ ] Date of Last PPE Inventory Check
[ ] Areas/Tasks Requiring Specific PPE (High-Risk Procedures, Contact with Infected Patients, Laboratory Work, Environmental Cleaning)
[ ] Any Deviations or Concerns Regarding PPE Usage?
[ ] Photograph of Proper PPE Usage (Optional)

--- ENVIRONMENTAL CLEANING & DISINFECTION ---
[ ] Date of Cleaning
[ ] Time of Cleaning
[ ] Cleaning Product Used (Bleach Solution, Quaternary Ammonium, Hydrogen Peroxide, Other (Specify))
[ ] Areas Cleaned (Be Specific)
[ ] Contact Time (in minutes)
[ ] Surfaces Disinfected (Bed Rails, Overbed Table, Floors, Equipment Surfaces, Doorknobs)
[ ] Cleaner Signature

--- STERILIZATION & HIGH-LEVEL DISINFECTION ---
[ ] Cycle Load Number
[ ] Sterilization Date
[ ] Sterilization Start Time
[ ] Temperature (Internal)
[ ] Pressure
[ ] Exposure Time (Minutes)
[ ] Cycle Type (Gravity, Vacuum, Steam Flush)
[ ] Sterilant Used (Steam, Hydrogen Peroxide, Glutaraldehyde)
[ ] Cycle Printout/Record

--- WASTE MANAGEMENT & DISPOSAL ---
[ ] Date of Waste Generation
[ ] Waste Category (Sharps, Biohazardous, Pharmaceutical, Regulated Medical Waste, General Waste)
[ ] Estimated Waste Volume (liters/gallons)
[ ] Description of Waste Contents (e.g., type of medication, specific biohazard)
[ ] Container Type (Red Bag, Sharps Container, Yellow Container, Other)
[ ] Waste Generator Signature
[ ] Waste Collection Point

--- PATIENT ISOLATION PROCEDURES ---
[ ] Isolation Type (Contact Precautions, Droplet Precautions, Airborne Precautions, Protective Isolation, Reverse Isolation)
[ ] Reason for Isolation
[ ] Patient Room Number
[ ] Isolation Start Date
[ ] Isolation Start Time
[ ] PPE Required (Select all that apply) (Gloves, Gown, Mask, N95 Respirator, Eye Protection (Face Shield or Goggles))
[ ] Specific Isolation Instructions

--- EMPLOYEE HEALTH & VACCINATION ---
[ ] Last Tdap Vaccination Date
[ ] Last MMR Vaccination Date
[ ] Last Varicella (Chickenpox) Vaccination Date
[ ] Hepatitis B Vaccination Status (Not Vaccinated, Completed Series, Declined Vaccination)
[ ] Number of Influenza Vaccinations Received (this year)
[ ] TB Screening Status (Negative, Positive, Unknown)
[ ] Upload Vaccination Records (optional)
[ ] Any Known Allergies Related to Vaccines?

--- SURVEILLANCE & REPORTING OF INFECTIONS ---
[ ] Date of Infection Detection
[ ] Patient Age
[ ] Infection Type (Healthcare-Associated Pneumonia, Catheter-Associated Urinary Tract Infection, Surgical Site Infection, Methicillin-Resistant Staphylococcus aureus (MRSA) Infection, Clostridioides difficile Infection, Other (Specify))
[ ] Description of Symptoms & Findings
[ ] Confirmed/Suspected (Confirmed, Suspected)
[ ] Number of Cases (if outbreak)
[ ] Date of Reporting to Public Health Agency

--- EDUCATION & TRAINING OF STAFF ---
[ ] Last Training Date
[ ] Training Module Completed (Select All) (Hand Hygiene, PPE Usage, Environmental Cleaning, Isolation Precautions, Infection Reporting, New Protocol Updates)
[ ] Hours of Training Completed (Total)
[ ] Summary of Key Training Points
[ ] Upload Training Certificate/Record
[ ] Trainer Name (Trainer 1, Trainer 2, Trainer 3)

--- EQUIPMENT MAINTENANCE & CALIBRATION ---
[ ] Last Calibration Date
[ ] Calibration Result (e.g., Reading)
[ ] Acceptable Range (Lower Limit)
[ ] Acceptable Range (Upper Limit)
[ ] Calibration Status (Pass, Fail, Not Applicable)
[ ] Calibration Notes/Observations
[ ] Calibration Report (Optional)
[ ] Next Calibration Due Date

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