Hand Hygiene Observation Form
Date of Data Collection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Data Collection
*
Hour Minutes
AM
PM
AM/PM Option
Data Collector
First Name
Last Name
Unit Observation
*
Please Select
ARU
ED
ICU
MHU
MIU
MSU2
MSU3/IMC
NICU
PEDS
Surg Svcs
Role of the Health Care Professional (HCP) Observed
*
Please Select
CM/SW
Dietary
HSK/EVS
Lab
MD
NA
NP
OT/PT/ST
Pharm
Rad
RT
RN
Other
Entry or Exit?
*
Entry
Exit
Did the person wash/sanitize?
*
Yes
No
Contributing factors to NOT washing/sanitizing
Dispenser Location
Dispenser Empty/Broken
Equipment Shared
Hands full of supplies/meds
Improper use of Gloves - Did not wash before/after wearing gloves
Improper use of Gloves - Did not change gloves between patients/rooms
Improper use of Gloves - Wearing gloves in hallway, nurses station, computer, etc.
Follow person on entry or exit
Frequent entry or exit
Distracted
Other
Comments
Submit
Should be Empty: