Hospital Surface Risk Assessment Form
Evaluate and record contamination or risk levels of hospital surfaces to ensure a safe healthcare environment.
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital Area/Department
*
Please Select
Patient Room
Operating Theater
ICU
Emergency Room
Corridor
Nurse Station
Other
Surface Type
*
Please Select
Bed Rail
Door Handle
Light Switch
Table/Desk
Medical Equipment
Sink/Faucet
Other
Observed Contamination
*
No visible contamination
Minor dirt/debris
Visible stains/fluids
Biological material present
Risk Level Assessment
*
Low
Moderate
High
Frequency of Cleaning
*
After every use
Multiple times daily
Daily
Weekly or less
Unknown
Cleaning Protocol Compliance
*
Rows
Compliant
Partially Compliant
Not Compliant
Not Applicable
Surface visibly clean
1
2
3
4
Correct disinfectant used
5
6
7
8
Proper cleaning method applied
9
10
11
12
Surface Damage or Wear Noted
No damage
Minor scratches/chips
Significant wear/damage
Overall Cleanliness Rating
*
1
2
3
4
5
Additional Comments/Observations
Submit Assessment
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