Sterile Transfer Technique Checklist Form
Complete this checklist to document each step of the sterile transfer technique.
Observer Name
*
First Name
Last Name
Date and Time of Observation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Hand hygiene performed before starting?
*
Completed
Not Completed
Not Applicable
All materials and surfaces prepared and disinfected?
*
Completed
Not Completed
Not Applicable
Sterile gloves donned correctly?
*
Completed
Not Completed
Not Applicable
Sterile field maintained throughout procedure?
*
Yes
No
Not Applicable
Items transferred without contamination?
*
Yes
No
Not Applicable
Used materials disposed of properly?
*
Completed
Not Completed
Not Applicable
Any breaches in sterile technique observed?
*
No
Yes (explain below)
Comments or observations (if any)
Submit Checklist
Should be Empty: