Optometry Infection Control Checklist Form
Complete this checklist to record infection-control measures for your shift or visit. All items are essential for maintaining safety and hygiene in the optometry clinic.
Date of checklist completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinic or location name
*
Staff member completing checklist
*
Shift or time period
*
Morning
Afternoon
Evening
Other (please specify in notes)
Hand hygiene supplies checked and available
*
Soap dispensers filled
Hand sanitizer available
Paper towels stocked
Exam room and equipment disinfected
*
Exam chairs wiped
Diagnostic equipment cleaned
Surfaces disinfected
Reusable instrument sterilization completed
*
Instruments cleaned before sterilization
Autoclave or sterilizer used
Sterilization logs updated
Personal protective equipment (PPE) available and in use
*
Masks available
Gloves available
Eye protection available
PPE used during patient care
Waiting area cleaning and disinfection
*
Chairs and surfaces cleaned
High-touch areas disinfected
Biomedical and waste disposal completed
*
Sharps containers checked
Waste bins emptied
Biohazard waste handled properly
Overall issues, missing supplies, cleaning failures, or follow-up actions
Submit Checklist
Should be Empty: