Hospital Hygiene Standards Assessment Form
Systematic assessment of hygiene standards and compliance in hospital settings.
General Information
Please provide basic information about the hospital and assessment.
Hospital/Facility Name
*
Department/Unit Assessed
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor's Full Name
*
First Name
Last Name
Assessor's Position/Title
*
Assessment of Hygiene Standards
Evaluate each area according to the criteria below. Use the scale: 1 = Poor, 2 = Fair, 3 = Good, 4 = Very Good, 5 = Excellent.
Hygiene Criteria Evaluation
*
Rows
Score (1-5)
General Cleanliness of Facility
1
Hand Hygiene Facilities (sinks, sanitizers)
2
Staff Hand Hygiene Compliance
3
Waste Management/Disposal
4
Linen and Laundry Handling
5
Cleaning and Disinfection of Surfaces
6
Sterilization of Medical Equipment
7
Personal Protective Equipment Availability/Use
8
Restroom Cleanliness
9
Pest Control Measures
10
Which areas require immediate corrective action? (Select all that apply)
General Cleanliness
Hand Hygiene
Waste Management
Equipment Sterilization
Restroom Cleanliness
Other (please specify)
Overall hygiene rating for the assessed area
*
1
2
3
4
5
Comments or Recommendations
Assessor's Signature
*
Submit Assessment
Submit Assessment
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