Hand Hygiene Competency Form
Audit of Hand-Washing and Sanitising Competence.
Staff Member Name
First Name
Last Name
Date of Audit
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
1
Staff Member can explain the rationale for effective hand hygiene
Yes
No
Staff Member can identify factors to be followed that will enable effective hand hygiene to be performed
Yes
No
Staff Member can identify the 5 "Moments" of Hand Hygiene
Yes
No
Staff Member can demonstrate appropriate handwashing procedure
Yes
No
Staff Member can identify when it is appropriate to use hand sanitiser
Yes
No
Staff Member can demonstrate appropriate hand sanitiser application procedure
Yes
No
Notes / Comments
Name of Assessor
First Name
Last Name
Submit
Should be Empty: