Mobile Device Cleaning Compliance Confirmation Form
Please confirm that your mobile device has been cleaned according to workplace/device hygiene procedures.
Full Name
*
First Name
Last Name
Department
*
Please Select
IT
Operations
Facilities
Administration
Other
Date of Cleaning
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Device Type
*
Please Select
Smartphone
Tablet
Handheld Scanner
Other
Device ID or Serial Number
*
Cleaning Method Used
*
Alcohol-based wipe
Disinfectant spray and cloth
UV sanitization
Other
Was the device powered off before cleaning?
*
Yes
No
Were all external surfaces cleaned?
*
Yes
No
Any visible damage or issue observed after cleaning?
*
No issues observed
Minor scratches
Screen discoloration
Other (please specify)
Submit Confirmation
Should be Empty: