Home Infection Control Training Form
Register, assess, and provide feedback on your home infection control training experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Role in the Home
*
Please Select
Homeowner
Family Member
Caregiver
Housekeeper
Other
Have you previously received any infection control training?
*
Yes
No
Please rate your understanding of the following infection control practices BEFORE this training:
*
Rows
No Understanding
Basic Understanding
Good Understanding
Excellent Understanding
Hand Hygiene
1
2
3
4
Surface Disinfection
5
6
7
8
Use of Personal Protective Equipment (PPE)
9
10
11
12
Safe Waste Disposal
13
14
15
16
Please rate your understanding of the following infection control practices AFTER this training:
*
Rows
No Understanding
Basic Understanding
Good Understanding
Excellent Understanding
Hand Hygiene
17
18
19
20
Surface Disinfection
21
22
23
24
Use of Personal Protective Equipment (PPE)
25
26
27
28
Safe Waste Disposal
29
30
31
32
What did you find most useful in this training?
What topics would you like to learn more about?
Overall, how would you rate this training?
*
1
2
3
4
5
Signature (Please sign to confirm your participation)
*
Submit Training Form
Submit Training Form
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