Hand Hygiene Survey

Which department are you completing this survey for?

Name of the employee observed:

select

What role was the person you observed performing?

What type of Provider was observed?

Other Observation Noted

Observation Type:

Did the individual use hand hygiene?

What were the reasons?

Hands full of equipment/meds

Improper use of gloves/PPE

Frequent exit or entry

Following a person on exit or entry

Distracted

Dispenser location/empty

Other (state below)

Was the hand hygiene performed correctly?

Hand washing for 20 seconds per CDC guidelines, OR using alcohol-based hand sanitizer and rubbing hands until dry.

Which type of hand hygiene was performed?

Optional Comment

Was the patient in contact plus isolation?

Which shift is this observation?