Medical Equipment Cleaning Evaluation Checklist
Use this checklist to assess the cleanliness and readiness of medical equipment after cleaning.
Evaluation Details
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Evaluation
*
Hour Minutes
AM
PM
AM/PM Option
Facility / Department / Unit
*
Please Select
Emergency Department
ICU
Operating Room
Sterile Processing
Radiology
Laboratory
Other
Location / Room / Area
*
Equipment Name / Type
*
Please Select
Infusion Pump
Ventilator
Monitor
Defibrillator
Ultrasound Machine
Wheelchair
Other
Equipment Asset ID / Internal Reference
Equipment Serial Number
Cleaning Process Information
Cleaner or Technician Name
*
Cleaning Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Cleaning Method Used
*
Please Select
Manual wipe-down
Ultrasonic cleaning
Automated washer-disinfector
Steam cleaning
High-level disinfection
Other
Cleaning Products or Disinfectants Used
Manufacturer Instructions or Internal Procedure Followed
*
Yes
No
Inspection Checklist and Ratings
Visible soil or debris
*
Pass
Fail
Needs Attention
Residue present
*
Pass
Fail
Needs Attention
Stains present
Pass
Fail
Needs Attention
Moisture or dryness status
*
Dry
Slightly damp
Wet
Needs Attention
Disinfected surfaces rating
*
1
2
3
4
5
Hard-to-reach areas
*
Clean
Needs Attention
Not Accessible
Attachments or accessories condition
Acceptable
Incomplete
Damaged
Needs Attention
Overall compliance rating
*
Compliant
Non-compliant
Needs Review
Findings and Follow-Up
Issues Observed
*
Corrective Actions Required
*
Is Re-Cleaning Needed?
*
Yes
No
Priority / Urgency of Follow-Up
*
Please Select
Low
Medium
High
Urgent
Evaluator Comments / Notes
Submit Evaluation
Should be Empty: