Resource Format: Checklist

Legionella Environmental Assessment Form (LEAF)

This fillable form can be used to document a facility’s water systems, help determine whether to conduct Legionella environmental sampling, and, if so, develop a sampling plan. An accompanying guide provides instructions and additional considerations for using the fillable form. The guide helps the evaluation team to understand form questions and also more fully assess potential risks in the facility’s water system. The form is available at: https://www.cdc.gov/legionella/downloads/legionella-environmental-assessment-marking-guide-508.pdf

3 – Intermediate
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Adult Day Care
All settings
Ambulatory (Outpatient) Care
Ambulatory Surgery
Any Practice Setting
Assisted Living Facility (ALF)
Auditing / Observation / Monitoring / Assessment Tools
Behavioral Health Facilities
CDC
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Construction
Dental
Department of Health
Dialysis
Downloadable
Emergency Medical Services (EMS)
English
Free
Home Health
Hospice and Palliative Care
Infection Preventionists
Mobile Clinic
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Pediatric / NICU
Physical Environment / Environment of Care (EOC)
Print Resources
Quality Improvement
Respiratory Infections
Risk Assessment
Select pathogens of public health concern
Water Management

VDH Environmental Checklist

This is a checklist as an EXCEL worksheet that can be used electronically or printed. It provides a list of expected cleaning tasks. It can be edited to individualize it for different facilities.

2 – Foundational
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Adult Day Care
All settings
Ambulatory (Outpatient) Care
Ambulatory Surgery
Any Practice Setting
Assisted Living Facility (ALF)
Behavioral Health Facilities
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Dental
Department of Health
Dialysis
Downloadable
Emergency Medical Services (EMS)
English
Free
Home Health
Hospice and Palliative Care
Infection Preventionists
Mobile Clinic
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Pediatric / NICU
Physical Environment / Environment of Care (EOC)
Spreadsheet
Standard Precautions
VDH

VDH Environmental Checklist for Blood Spills

This is a checklist as an EXCEL worksheet that can be used electronically or printed. It provides a list of expected cleaning tasks to be performed after a spill of blood or other potentially infectious bodily fluids. It can be edited to individualize it for different facilities.

2 – Foundational
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Adult Day Care
All settings
Ambulatory (Outpatient) Care
Ambulatory Surgery
Any Practice Setting
Assisted Living Facility (ALF)
Behavioral Health Facilities
Bloodborne Pathogens
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Dental
Department of Health
Dialysis
Downloadable
Emergency Medical Services (EMS)
English
Free
Hand Hygiene
Home Health
Hospice and Palliative Care
Infection Preventionists
Injection Safety
Mobile Clinic
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Pediatric / NICU
Personal Protective Equipment (PPE)
Physical Environment / Environment of Care (EOC)
Spreadsheet
Standard Precautions
VDH

Infection Prevention Quick Guide: Environment of Care

This is a 2-page checklist to guide the development of a plan for conducting environmental rounds at a scheduled frequency. It provides a list of key items to include during environmental rounds.

2 – Foundational
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Adult Day Care
All settings
Ambulatory (Outpatient) Care
Ambulatory Surgery
Any Practice Setting
Assisted Living Facility (ALF)
Auditing / Observation / Monitoring / Assessment Tools
Behavioral Health Facilities
Checklist
Clinical / Direct Healthcare Personnel
Dental
Department of Health
Dialysis
Downloadable
Emergency Medical Services (EMS)
English
Free
Home Health
Hospice and Palliative Care
Infection Preventionists
Injection Safety
Mobile Clinic
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Pediatric / NICU
Physical Environment / Environment of Care (EOC)
Quality Improvement
Risk Assessment
VDH

Environmental Rounds Worksheet For Infection Prevention

This is a 5 page checklist that is intended for teams that are conducting infection prevention environmental rounding. It is designed for rounding in a hospital, but as a WORD-based document, can be adapted for other healthcare settings.

3 – Intermediate
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Adult Day Care
Ambulatory (Outpatient) Care
Ambulatory Surgery
Assisted Living Facility (ALF)
Auditing / Observation / Monitoring / Assessment Tools
Behavioral Health Facilities
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Dental
Department of Health
Dialysis
Downloadable
English
Free
High Level Disinfection
Hospice and Palliative Care
Infection Preventionists
Injection Safety
Mobile Clinic
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Pediatric / NICU
Personal Protective Equipment (PPE)
Physical Environment / Environment of Care (EOC)
Quality Improvement
Risk Assessment
SPICE
Standard Precautions
Sterile Processing

Clostridioides difficile-Event Analysis Hospital Quality and Patient Safety

This is a 5-page fillable pdf form that can be used to guide event analysis or root-cause analysis after a patient develops a Clostridioides difficile infection.

3 – Intermediate
Acute Care Hospital
Acute Care Rehabilitation or Long-Term Care Acute Hospital (LTACH)
Antimicrobial & Diagnostic Stewardship
Assisted Living Facility (ALF)
Auditing / Observation / Monitoring / Assessment Tools
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Clostridioides difficile
Downloadable
English
Fillable PDF
Free
Gastrointestinal Infections
Hand Hygiene
HQIN
Infection Preventionists
Laboratory Collection and Interpretation
Nursing Home / Skilled Nursing Facility (SNF)
Patient and Family Engagement
Pediatric / NICU
Physical Environment / Environment of Care (EOC)
Print Resources
Quality Improvement
Risk Assessment
Standard Precautions
Transmission-Based Precautions

Infection Prevention Quick Guide: Airborne Precautions

This is a single page information sheet or poster that outlines the elements and requirements for airborne precautions in the long term care setting. It has a second page to aid in how to communicate about the precautions to residents and to healthcare workers and has a link to additional resources.

2 – Foundational
Assisted Living Facility (ALF)
Checklist
Clinical / Direct Healthcare Personnel
Downloadable
English
Free
Infection Preventionists
Inter-/Intra-Facility Patient Transfer
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Patient and Family Engagement
Patients, Family, Visitors, Unpaid Caregivers
Personal Protective Equipment (PPE)
Print Resources
Respiratory Infections
Transmission-Based Precautions
Tuberculosis (TB)
VDH

Infection Prevention Quick Guide: Candida auris

This is a 2-paged document that can be used as a checklist, education flyer, or poster explaining the infection prevention elements related to C. auris. It provides possible language to use when messaging residents and their families about infection or colonization, and when messaging healthcare workers about recommended precautions and why they are necessary.

2 – Foundational
Assisted Living Facility (ALF)
Checklist
Cleaning and Disinfection
Clinical / Direct Healthcare Personnel
Downloadable
English
Enhanced Barrier Precautions (EBP)
Free
Hand Hygiene
Infection Preventionists
Inter-/Intra-Facility Patient Transfer
Multidrug-Resistant Organism (MDRO)
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Patient and Family Engagement
Patients, Family, Visitors, Unpaid Caregivers
Personal Protective Equipment (PPE)
Physical Environment / Environment of Care (EOC)
Print Resources
Transmission-Based Precautions
VDH

Infection Prevention Quick Guide: Carbapenem-Resistant Organisms (CROs) and Carbapenemase-Producing Organisms (CPOs)

This is a 2-paged document that can be used as a checklist or education flyer explaining the infection prevention elements related to Carbapenem-Resistant organisms (CROs) and Carbapenemase-Producing Organisms (CPOs). It provides possible language to use when messaging residents and their families about infection or colonization, and when messaging healthcare workers about recommended precautions and why they are necessary.

2 – Foundational
Assisted Living Facility (ALF)
Checklist
Clinical / Direct Healthcare Personnel
Downloadable
English
Enhanced Barrier Precautions (EBP)
Free
Hand Hygiene
Infection Preventionists
Inter-/Intra-Facility Patient Transfer
Multidrug-Resistant Organism (MDRO)
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Patient and Family Engagement
Patients, Family, Visitors, Unpaid Caregivers
Personal Protective Equipment (PPE)
Print Resources
Transmission-Based Precautions
VDH

Pre-Implementation Tool—Enhanced Barrier Precautions (EBP)

This is a 4-paged fillable pdf formatted tool designed to be used prior to implementation of enhanced barrier precautions in a facility (either a unit, wing, or entire facility). It is intended for use in skilled nursing facilities/nursing homes.

Intermediate
Assisted Living Facility (ALF)
Auditing / Observation / Monitoring / Assessment Tools
CDC
Checklist
Clinical / Direct Healthcare Personnel
Downloadable
English
Enhanced Barrier Precautions
Free
Hand Hygiene
Infection Preventionists
Non-Clinical / Indirect Healthcare Personnel
Nursing Home / Skilled Nursing Facility (SNF)
Personal Protective Equipment (PPE)
Print Resources
Quality Improvement
Risk Assessment
Standard Precautions