Surface Contamination Risk Assessment Form
Complete this assessment to evaluate the risk of contamination on surfaces. Please answer all questions for an accurate risk profile.
Surface Location
*
Please Select
Office
Restroom
Kitchen
Lobby/Reception
Meeting Room
Warehouse
Other
Surface Type
*
Desk/Table
Door Handle
Light Switch
Countertop
Equipment Control
Other
Frequency of Surface Use
*
Constant (multiple times per hour)
Frequent (hourly)
Occasional (few times per day)
Rare
Frequency of Cleaning/Disinfection
*
After each use
Multiple times per day
Daily
Weekly or less often
Type of Contaminants Most Likely Present
*
Dust/Dirt
Food Residue
Body Fluids (e.g., saliva, sweat)
Chemical Residue
Other
Assessment of Cleaning Effectiveness
*
1
2
3
4
5
Risk Factor Evaluation
*
Rows
Low
Medium
High
Surface Touch Frequency
1
2
3
Number of Unique Users
4
5
6
Cleaning Accessibility
7
8
9
Presence of Visible Contaminants
10
11
12
Describe Any Observed Issues or Concerns
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name
First Name
Last Name
Submit Assessment
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