Observer: ________________________________________________

Date: ________________ Time: _________ Dept: ________________

HH resources: _____________________

Moment/Method

DOCTOR

NURSE

PATIENT

STAFF

STUDENT

VISITOR

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

BEFORE touching a patient

WASH

RUB

BEFORE “Clean” procedure

WASH

RUB

AFTER PATIENT body fluid exposure risk

WASH

RUB

AFTER PERSONAL body fluid exposure risk

WASH

RUB

AFTER touching a patient

WASH

RUB

AFTER touching patient surroundings

WASH

RUB