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F-QM-IC-001-A-V0 — Infection Prevention, Hand Hygiene, Cleaning & Biological Spill Log

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-IC-001 — Infection Prevention, Hand Hygiene, and Healthcare Waste Management Policy (parent is encoded in the form number)

Rendered in-browser from the project's Word file F-QM-IC-001-A-V0-infection-prevention-and-control-audit-checklist.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.

Document #	F-QM-IC-001-A-V0	Parent Document	LAB-QM-IC-001 — Hand Hygiene and Infection Control Policy

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Part 1 — General IPC Compliance & Daily Cleaning Checklist

Audit Ref No.:	IPC-AUD-YYYY-____	Audit Period:	[ ] Monthly [ ] Quarterly	Date:	YYYY-MM-DD
Auditor Name:	________________________________, RMT	Lead Overseer:	Chief Medical Technologist / LQM

1.1 General Infection Control & Facility Hygiene Practices

Audit Item	Status (Compliant / Non-Compliant)	Observations / Action Required
1. Dedicated laboratory coats/gowns worn inside technical areas; removed before leaving	[ ] Compliant [ ] Non-Compliant
2. Closed-toe impermeable footwear worn at all times by laboratory personnel	[ ] Compliant [ ] Non-Compliant
3. Eating, drinking, smoking, cosmetics application, and food storage strictly prohibited	[ ] Compliant [ ] Non-Compliant
4. Workbenches disinfected twice daily (start and end of shift) and after any contamination	[ ] Compliant [ ] Non-Compliant
5. Surface disinfectant (1:9 freshly prepared household bleach) dated and labeled daily	[ ] Compliant [ ] Non-Compliant
6. Handwashing sink provided with liquid soap, running water, and single-use paper towels	[ ] Compliant [ ] Non-Compliant
7. Alcohol-based hand rub (ABHR) dispensers available and stocked at phlebotomy and benches	[ ] Compliant [ ] Non-Compliant

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Part 2 — Hand Hygiene Compliance Observation (WHO 5 Moments)

Observe staff across at least 10 opportunities during phlebotomy, specimen handling, and testing.

Opportunity #	Role: [MT] Technologist / [LA] Aide	WHO Moment Observed (1: Before patient; 2: Clean procedure; 3: Body fluid risk; 4: After patient; 5: After surroundings)	Hand Hygiene Action: [ABHR] Alcohol Rub / [HW] Soap & Water / [Missed] None	Compliance Result: [✓] Compliant / [X] Missed
1	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
2	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
3	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
4	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
5	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
6	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
7	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
8	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
9	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed
10	[ ] MT [ ] LA	[ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5	[ ] ABHR [ ] HW [ ] Missed	[ ] Compliant [ ] Missed

Hand Hygiene Compliance Rate (%): (Compliant Moments / Total Observed) × 100 = ______ % (Target: >= 90%)

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Part 3 — Healthcare Waste Segregation & Sharps Monitoring

Waste Category	Standard Requirements	Compliant (Yes / No)
Yellow Bag (Infectious Waste)	Contaminated blood tubes, tips, gauze, cotton balls, gloves	[ ] Yes [ ] No
Black Bag (General Waste)	Paper towels, outer packaging, clean office waste	[ ] Yes [ ] No
Yellow Sharps Box	Puncture-proof, sealed at 3/4 full line, unrecapped needles only	[ ] Yes [ ] No
Broken Glass Bin	Dedicated rigid container; slides and broken ESR tubes	[ ] Yes [ ] No

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Part 4 — Biological Spill Response & Decontamination Log

Spill Protocol: Wear gloves, lab coat, face shield. Cover spill with absorbent towels. Flood with freshly prepared 1:9 bleach (or 1:5 bleach for spills >10 mL). Allow 20 minutes contact time. Remove broken glass with forceps. Double-bag in yellow biohazard container.

Spill No.	Incident Date & Time	Spill Kit Used?	Disinfectant & Contact Time Applied	Broken Glass Picked with Forceps?	Staff Exposure Occurred?
1	YYYY-MM-DD HH:MM	[ ] Yes [ ] No	Bleach 1:9 / 20 min	[ ] Yes [ ] NA	[ ] Yes [ ] No
2	YYYY-MM-DD HH:MM	[ ] Yes [ ] No	Bleach 1:9 / 20 min	[ ] Yes [ ] NA	[ ] Yes [ ] No
3	YYYY-MM-DD HH:MM	[ ] Yes [ ] No	Bleach 1:9 / 20 min	[ ] Yes [ ] NA	[ ] Yes [ ] No

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Part 5 — Review and Supervisory Endorsement

5.1 Medical Technologists

We confirm that technical examinations were performed using standard biosafety precautions and biological spills were decontaminated per protocol.

Technologist Name	PRC License Number	Date	Signature

5.2 Laboratory Aides

We confirm that healthcare waste bags were tied when 3/4 full, sharps containers checked daily, and daily cleaning verified.

Laboratory Aide Name	Assigned Duty Station	Date	Signature

5.3 Chief Medical Technologist / Laboratory Quality Manager

Summary Evaluation: [ ] Hand hygiene target met [ ] Zero untreated spills
Signature: ________________________________________ Date: ____________________

5.4 Pathologist / Head of Laboratory

Signature: ________________________________________ Date: ____________________