Infection Control Care Shift Report Form
Document and communicate infection control status, observations, and actions during your care shift.
Shift Date and Time
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Shift Type
*
Day
Evening
Night
Other
Unit/Location
*
Reporter Name and Role
*
Patient/Resident or Care Area ID
*
Infection Control Observations
*
Personal Protective Equipment (PPE) Used
*
Gloves
Gown
Surgical Mask
N95 Respirator
Face Shield/Goggles
None
Other
Isolation Precautions in Place
*
Standard Precautions
Contact Precautions
Droplet Precautions
Airborne Precautions
No Isolation
Other
Hand Hygiene Compliance
*
Compliant
Non-Compliant
Partially Compliant
Not Observed
Environmental Cleaning Status
*
Completed
Partially Completed
Not Completed
Not Applicable
Incidents or Exposures (Describe any infection control incidents, exposures, or near misses during the shift)
Supplies/Concerns (Report any supply shortages or infection control concerns)
Follow-up Actions Needed
Submit
Should be Empty: