Nursing Cleaning Checklist Form
Record routine cleaning and sanitization tasks completed by nursing staff in the care setting.
Staff Member Name
*
First Name
Last Name
Date and Time of Cleaning
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location/Area Cleaned
*
Please Select
Patient Room
Nursing Station
Bathroom
Hallway
Kitchen
Other
Cleaning Tasks Completed
*
Surfaces wiped/disinfected
Floors cleaned
Trash removed
Bathroom sanitized
High-touch areas disinfected
Other
Status of Cleaning
*
Completed
Partially Completed
Not Completed
Supplies Used
Disinfectant
Gloves
Mop/Bucket
Paper Towels
Other
Were any issues found during cleaning?
*
No Issues Found
Yes (please describe below)
Describe any issues found
Additional Comments
Staff Signature
*
Submit Checklist
Submit Checklist
Should be Empty: