Surgical Room Monitoring Survey
Please provide your observations and feedback regarding the surgical room conditions and procedures.
Date of Monitoring
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Monitoring
Hour Minutes
AM
PM
AM/PM Option
Room Cleanliness
Excellent
Good
Fair
Poor
Equipment Functionality
Fully Functional
Partially Functional
Non-functional
Staff Compliance with Protocols
Always
Mostly
Sometimes
Never
Any Incidents or Issues Observed? Please describe.
Additional Comments or Suggestions
Submit
Should be Empty: