QIBAH GENERAL HOSPITAL

QIBAH, AL GASSIM, KSA

INFECTION CONTROL DEPARTMENT

TERMINAL CLEANING CHECKLIST FOR ISOLATION ROOM

Date of Discharge: _______________________

NURSE HOUSEKEEPER
NAME OF STAFF

PPE USED (YES/NO)

(if Yes, mention those specifically)

Type of Disinfectant used and its

dilution
Time Entered

Time went outside the room

Signature

Supervised by: (Charge Nurse) _____________________________

Noted by: (Infection Control Department)_____________________