Healthcare Facility Cleaning Checklist Form
Track routine cleaning tasks and verify completion by area and shift.
Cleaning Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility Area
*
Please Select
Patient room or care area
Restroom
Waiting or reception area
Hallway or common area
Staff area
Other area
Shift
*
Morning
Afternoon
Evening
Overnight
High-Touch Surfaces
*
Door handles and push plates
Light switches and control panels
Counters and work surfaces
Shared equipment exterior surfaces
Floors and Waste
*
Floor swept or vacuumed
Floor mopped as appropriate
Waste bins emptied
Waste liners replaced
Restroom Cleaning
*
Fixtures cleaned
Sinks and counters cleaned
Mirrors cleaned
Supplies replenished
Cleaning Supplies and Equipment
*
Approved cleaning products used as directed
Cleaning equipment cleaned after use
Supplies returned to designated storage
Final Area Check
*
Area left orderly
Wet-floor signs used when needed
Cleaning completed according to site procedure
Cleaning Issues or Tasks Requiring Follow-Up
Overall Completion Status
*
Complete
Partially complete
Unable to complete
Submit Checklist
Should be Empty: