EVS Checklist Template
Author: Toledo-Lucas County Health Department (Wood County Health...
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EVS Checklist Template
This checklist is designed to support thorough cleaning of high touch surfaces in patient and resident rooms. Users record which items were cleaned or not cleaned in each room, providing a clear documentation trail for infection prevention purposes. The checklist reminds staff to follow essential safety protocols before and during cleaning, including proper hand hygiene using soap and water or alcohol-based hand sanitizer, wearing gloves, leaving the cleaning cart outside the room, and knocking before entering. Staff are also reminded to respect the privacy and dignity of patients and residents throughout the cleaning process.
Program: Community Health
Submitted Date: Feb 23, 2026 | Modified Date: Feb 24, 2026
Primary Toolkit: IPC Resource Library | Secondary Toolkit: N/A
Jurisdiction: county
Institution Type: LHD - County,
Keywords: IPC Resource Library, Healthcare-Associated Infections (HAI), Infectious Disease, Long-Term Care Facility, Nursing Home
