Respiratory Infection Contact Precautions Checklist Form
Complete this checklist to document status and actions taken for respiratory infection contact precautions.
Date of Checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Name
*
Patient Room/Location
*
Type of Respiratory Precautions Implemented
*
Contact precautions
Droplet precautions
Airborne precautions
Other
Personal Protective Equipment (PPE) Used
*
Gloves
Gown
Mask/Respirator
Eye protection
Not applicable
Hand Hygiene Performed Before and After Patient Contact
*
Before contact
After contact
Not performed
Contact Precautions Signage Posted Outside Room
*
Signage visible
Signage missing
PPE Supplies Available at Point of Care
*
All supplies available
Supplies missing
Proper Waste Disposal Used for PPE
*
Yes
No
Cleaning/Disinfection of High-Touch Surfaces Completed
*
Completed
Not completed
Additional Comments or Observations
Submit Checklist
Should be Empty: