Healthcare Cleaning Monitoring Form

HEALTHCARE CLEANING MONITORING FORM

Purpose: To document cleaning and disinfection activities, monitoring results, and any corrective actions taken for patient care areas, equipment, or facility spaces. Records created on this form are facility business records and must be accurate and complete.

Facility & Location

Room / Area:   Bed / Room Number:   Patient Affected (if applicable):

Date of Cleaning:   Time of Cleaning:

Staff Performing Cleaning

Cleaning Tasks (check all completed)

High-touch surfaces cleaned and disinfected

Floors cleaned / mopped

Bathroom / sanitary fixtures cleaned

Linen changed and handled per protocol

Medical equipment disinfected

Terminal cleaning completed

Waste and sharps removed and disposed appropriately

Cleaning Product & Process Details

Dilution / Concentration:   Contact Time (minutes):

Monitoring Method & Results

Visual Inspection: Pass Fail   Inspector initials:

ATP Test Performed:   ATP Reading:   Threshold for Pass:   Result: Pass Fail

Microbiology Swab Collected:   Lab Result (if available):

Non‑Conformance & Corrective Action

Non‑Conformance Identified: Yes No

Time to Correction:   Notified Supervisor:

Supervisor Review & Verification

Supervisor Name:   Date of Review:

Certification

I certify under penalty of facility disciplinary action that the information contained in this form is true and accurate to the best of my knowledge. I further attest that cleaning and disinfection were performed in accordance with facility policies and manufacturer instructions for use. Falsification or intentional omission of monitoring records is subject to disciplinary action.

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