Infection Control Compliance Report
Report and assess infection control practices to ensure compliance and safety standards are met.
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location/Department
*
Name of Inspector
*
First Name
Last Name
Role/Title of Inspector
*
Observed Area/Unit
*
Please Select
Patient Room
Operating Room
Nursing Station
Restrooms
Cafeteria
Other
Infection Control Compliance Assessment
*
Rows
Compliant
Non-Compliant
Not Applicable
Hand Hygiene Performed
1
2
3
Personal Protective Equipment (PPE) Used Correctly
4
5
6
Proper Disposal of Waste
7
8
9
Cleaning and Disinfection of Surfaces
10
11
12
Safe Injection Practices
13
14
15
Additional Observations
Were any non-compliance issues identified?
*
Yes
No
If yes, describe non-compliance issues and corrective actions taken
Responsible Person for Corrective Actions
First Name
Last Name
Compliance Rating
*
1
2
3
4
5
Signature of Inspector
*
Submit Report
Submit Report
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