Infection Control Monthly Compliance Report
Please complete this form to document and assess infection control compliance for your facility this month.
Facility/Unit Name
*
Reporting Period (Month and Year)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Person Completing Report
*
First Name
Last Name
Role/Position
*
Contact Email
*
example@example.com
Infection Control Compliance Checklist
*
Rows
Compliant
Non-Compliant
Not Applicable
Hand hygiene practices are followed by staff
1
2
3
Personal protective equipment (PPE) is used appropriately
4
5
6
Cleaning and disinfection protocols are adhered to
7
8
9
Waste is disposed of according to infection control policies
10
11
12
Sharps containers are available and not overfilled
13
14
15
Isolation precautions are implemented when necessary
16
17
18
Staff have received infection control training
19
20
21
Were any infection control incidents or breaches reported this month?
*
Yes
No
If yes, please describe the incident(s) and actions taken
Additional comments or suggestions for improvement
Reviewer/Manager Name
First Name
Last Name
Submit Report
Should be Empty: