CPR Manikin Cleaning Checklist
Complete this form to document and verify the cleaning and maintenance of CPR training manikins.
Staff Member Name
*
First Name
Last Name
Date of Cleaning
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Manikin Identification Number or Name
*
Location of Cleaning
*
Pre-Cleaning Condition
*
Clean
Slightly Soiled
Heavily Soiled
Cleaning Steps Completed
*
Rows
Completed
Not Applicable
Removed and discarded disposable parts (if any)
1
2
Cleaned exterior surfaces with approved disinfectant
3
4
Cleaned airway and face areas
5
6
Checked for visible residue or damage
7
8
Allowed manikin to air dry completely
9
10
Cleaning Materials Used
*
Disinfectant wipes
Soap and water
Alcohol-based cleaner
Other
Post-Cleaning Condition
*
Clean and ready for use
Needs repair/maintenance
Notes or Observations
Inspector/Supervisor Name
*
First Name
Last Name
Inspector/Supervisor Signature
*
Submit Checklist
Submit Checklist
Should be Empty: