ISOLATION ROOM CLEANING & DECONTAMINATION CHECKLIST

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--- PRE-CLEANING ASSESSMENT & PREPARATION ---
[ ] Date of Cleaning/Decontamination
[ ] Start Time of Cleaning/Decontamination
[ ] Patient Status (Prior to Cleaning) (Active Isolation, Discharged, Transfered, Deceased)
[ ] Reason for Cleaning/Decontamination (e.g., Routine, Discharge, Known Exposure)
[ ] Isolation Type (e.g., Airborne, Contact, Droplet, PUI) (Airborne, Contact, Droplet, Person Under Investigation (PUI), Other)
[ ] Notes on Patient Condition or Potential Hazards
[ ] Room Number
[ ] Supporting Documentation (e.g., Patient Isolation Order)

--- PERSONAL PROTECTIVE EQUIPMENT (PPE) ---
[ ] Gown Type (Standard Isolation Gown, Fluid-Resistant Gown)
[ ] PPE Donned (Check all that apply) (Gloves, N95 Respirator, Eye Protection (Goggles/Face Shield), Mask, Gown)
[ ] Respirator Fit Check Performed? (Yes, No)
[ ] Time of PPE Donning
[ ] Notes regarding PPE condition/fit (if any)

--- INITIAL ROOM ASSESSMENT & WASTE REMOVAL ---
[ ] Date of Isolation Room Use End
[ ] Time of Isolation Room Use End
[ ] Patient Status (e.g., Discharged, Deceased) (Discharged, Transferred, Deceased, Other)
[ ] Reason for Room Decontamination (Brief description)
[ ] Observed Hazards (Check all that apply) (Visible Contamination (Blood, Body Fluids), Broken Equipment, Spills, Unidentified Objects, None Observed)
[ ] Description of Observed Hazards (if any)
[ ] Quantity of Infectious Waste Bags
[ ] Waste Types Removed (Check all that apply) (Regular Waste, Infectious Waste, Sharps Waste, Other)

--- SURFACE CLEANING - LOW TOUCH AREAS ---
[ ] Ceiling Cleanliness (Visual Inspection) (Clean, Slight Dust/Dirt, Significant Dirt/Stains, Not Applicable)
[ ] Window Frame Cleanliness (Visual Inspection) (Clean, Slight Dust/Dirt, Significant Dirt/Stains, Not Applicable)
[ ] Baseboard Cleanliness (Visual Inspection) (Clean, Slight Dust/Dirt, Significant Dirt/Stains, Not Applicable)
[ ] Notes on Low-Touch Area Cleaning (e.g., unusual stains, damage)
[ ] Door Frame Cleanliness (excluding handle) (Clean, Slight Dust/Dirt, Significant Dirt/Stains, Not Applicable)

--- SURFACE CLEANING - HIGH TOUCH AREAS ---
[ ] Door Handles (Interior & Exterior) (Cleaned & Disinfected, Not Applicable)
[ ] Light Switches (Cleaned & Disinfected, Not Applicable)
[ ] Call Buttons/Nurse Call System (Cleaned & Disinfected, Not Applicable)
[ ] Bedside Table/Surface (Cleaned & Disinfected, Not Applicable)
[ ] IV Pole (Cleaned & Disinfected, Not Applicable)
[ ] Overbed Table (Cleaned & Disinfected, Not Applicable)
[ ] Number of IV pump handles cleaned

--- DECONTAMINATION PROCEDURES ---
[ ] Disinfectant Type Used (Sodium Hypochlorite (Bleach), Quaternary Ammonium Compound, Hydrogen Peroxide, Other (Specify in LONG_TEXT))
[ ] If 'Other' Disinfectant Selected, Specify
[ ] Disinfectant Contact Time (Minutes)
[ ] Areas Decontaminated (Detailed)
[ ] Decontamination Method (Spray Application, Wipe Down, Fogging/Misting)
[ ] Photo Documentation (Optional)
[ ] Decontamination Start Time
[ ] Decontamination End Time

--- EQUIPMENT CLEANING & DISINFECTION ---
[ ] Type of Equipment Being Cleaned: (Bed (including frame and mattress), Overbed Table, IV Pole, Chair(s), Medical Cart, Monitoring Equipment (Specify in LONG_TEXT), Other (Specify in LONG_TEXT))
[ ] Specify Monitoring Equipment (If selected above):
[ ] Cleaning Agent Used: (EPA-Registered Disinfectant 1, EPA-Registered Disinfectant 2, Facility Standard Disinfectant, Other (Specify in LONG_TEXT))
[ ] Specify Disinfectant (If 'Other' selected above):
[ ] Contact Time (in minutes):
[ ] Photo Documentation (Optional):
[ ] Equipment Surfaces Cleaned: (All Surfaces, High-Touch Surfaces Only)
[ ] Cleaner Signature
[ ] Time of Cleaning

--- POST-CLEANING VERIFICATION & RESIDUAL DISINFECTANT REMOVAL ---
[ ] Room Airflow Verification (if applicable)
[ ] Visual Inspection - Dampness (No Dampness Observed, Slight Dampness Observed (addressed), Significant Dampness Observed (requires further action))
[ ] Residual Disinfectant Odor (No Odor Present, Mild Odor Present (within acceptable range), Strong Odor Present (requires further ventilation/action))
[ ] Ventilation Time (minutes)
[ ] Surface Dryness Verification (Surfaces are Dry, Surfaces are Damp (addressed))
[ ] Notes/Comments (e.g., any issues encountered or corrective actions taken)
[ ] Verification Date
[ ] Verification Time
[ ] Verifying Personnel Signature

--- WASTE DISPOSAL ---
[ ] Waste Stream Segregation - Identify and segregate waste streams: (General Waste, Biohazardous Waste (Red Bag), Sharps Waste (Puncture Resistant Container), Regulated Medical Waste (RMW), Pharmaceutical Waste)
[ ] Number of Red Bags Used
[ ] Number of Sharps Containers Used/Filled
[ ] Waste Container Condition - Describe condition of waste containers prior to use: (New, Used (Clean), Used (Slightly Soiled) - Cleaned, Damaged - Not Usable)
[ ] Comments/Observations Regarding Waste Disposal
[ ] Waste Transport - How was waste transported from the room? (Cart, Hand Carry, Other (Specify))
[ ] If 'Other' for Transport - Specify Transport Method:

--- PPE REMOVAL & HAND HYGIENE ---
[ ] Describe PPE Removal Procedure (e.g., donning/doffing sequence)
[ ] PPE Removed Correctly (Observe for contamination)? (Yes, No, Not Observed)
[ ] Hand Hygiene Duration (seconds)
[ ] Hand Hygiene Type Performed? (Soap & Water, Alcohol-Based Hand Rub)
[ ] Hand Hygiene Completion â€“ Observe for any skin irritation or issues? (Yes, No, Not Observed)
[ ] Cleaner Signature
[ ] Date of Hand Hygiene Observation

--- DOCUMENTATION & SIGN-OFF ---
[ ] Date of Cleaning/Decontamination
[ ] Start Time of Cleaning/Decontamination
[ ] End Time of Cleaning/Decontamination
[ ] Reason for Isolation (Patient Type) (Airborne Precautions, Droplet Precautions, Contact Precautions, Combination Precautions, Unknown/Other)
[ ] Patient Name (if applicable)
[ ] Any Unusual Observations or Issues Encountered During Cleaning/Decontamination
[ ] Cleaning Staff Signature
[ ] Reviewing Supervisor Signature
[ ] Room Status After Cleaning (Ready for Next Patient, Requires Further Assessment, Out of Service)

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