Infection Control and Isolation Assessment Questionnaire
This form is used to evaluate infection control measures and isolation procedures within your facility. Please answer all questions based on your observations and current practices.
Assessor's Full Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility/Department Name
*
Role/Position
*
Please Select
Infection Control Nurse
Physician
Department Head
Quality/Safety Officer
Other
Hand Hygiene and PPE Assessment
*
Rows
Always
Sometimes
Rarely
Never
Hand hygiene performed before and after patient contact
1
2
3
4
Appropriate use of gloves
5
6
7
8
Appropriate use of masks/respirators
9
10
11
12
Appropriate use of gowns/aprons
13
14
15
16
Hand hygiene after removing gloves
17
18
19
20
Isolation Precautions Assessment
*
Rows
Yes
No
Not Applicable
Isolation signage clearly posted
21
22
23
Dedicated equipment for isolated patients
24
25
26
Proper disposal of PPE after use
27
28
29
Visitor restrictions in place
30
31
32
Isolation protocols followed by all staff
33
34
35
How would you rate overall compliance with infection control protocols?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Are staff members regularly trained on infection control and isolation procedures?
*
Yes, all staff are regularly trained
Some staff are trained
Training is infrequent or not conducted
Environmental Cleaning Assessment
*
Rows
Compliant
Non-Compliant
Not Observed
High-touch surfaces cleaned regularly
36
37
38
Cleaning supplies available and accessible
39
40
41
Appropriate disinfectants used
42
43
44
Waste disposed of properly
45
46
47
Please describe any infection control concerns or incidents observed during this assessment.
Submit Assessment
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