Medical Scrub Training Evaluation Checklist
Use this checklist to evaluate and document scrub-training performance during medical training sessions.
Evaluator Name
*
First Name
Last Name
Trainee Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Checklist: Scrub Training Steps Completed
*
Handwashing technique demonstrated
Proper gowning procedure
Correct gloving technique
Maintained sterile field
Appropriate disposal of materials
Overall Adherence to Protocol
*
1
2
3
4
5
Communication with Team Members
*
1
2
3
4
5
Punctuality and Preparedness
*
1
2
3
4
5
Attention to Detail (Likert Scale)
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Attention to detail during gowning and gloving
1
2
3
4
5
Areas of Strength
Areas for Improvement / Additional Comments
Submit Evaluation
Should be Empty: