Universal Precautions Training Acknowledgement Form
Please complete this form to confirm your participation and understanding of the Universal Precautions Training.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department/Unit
*
Please Select
Nursing
Laboratory
Housekeeping
Administration
Maintenance
Other
Date of Training
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Trainer's Name
*
Which of the following are considered universal precautions? (Select all that apply)
*
Wearing gloves when handling blood or bodily fluids
Hand hygiene before and after patient contact
Reusing single-use equipment
Proper disposal of sharps
Not wearing personal protective equipment (PPE) when required
Other
Please rate your understanding of universal precautions after this training:
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
List two key practices you will implement to maintain universal precautions:
*
Signature
*
Submit Acknowledgement
Submit Acknowledgement
Should be Empty: