Decontamination Procedure Checklist
Please complete this checklist to ensure all decontamination steps have been properly performed and documented.
Personnel Information
Full Name of Person Performing Decontamination
*
First Name
Last Name
Job Title/Role
*
Date and Time of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location/Area Decontaminated
*
Decontamination Steps Checklist
*
Rows
Completed
Remove visible debris from surfaces
1
Apply appropriate cleaning agent
2
Allow contact time as per instructions
3
Rinse surfaces (if required)
4
Dispose of waste materials properly
5
Clean and store equipment used
6
Inspect area post-decontamination
7
Personal Protective Equipment (PPE) Used
*
Gloves
Gown or Apron
Face Shield/Goggles
Mask/Respirator
Boot/Shoe Covers
Other
Chemicals or Cleaning Agents Used (list all)
*
Were any issues or incidents encountered during the procedure?
*
No issues encountered
Yes, issues encountered (please describe below)
If issues or incidents occurred, please describe:
Supervisor/Manager Name (if applicable)
First Name
Last Name
Supervisor/Manager Review
Approved
Requires Follow-Up
Signature (Person Completing Checklist)
*
Submit Checklist
Submit Checklist
Should be Empty: