Tools and Forms

The Nebraska ICAP team frequently provides assistance to infection preventionists in setting up various infection control measures. During this process, sometimes we develop new tools for them or suggest use of certain tools/forms that are already available. We have compiled the more commonly used tools and forms and divided those into categories. Please click on the categories below to find all the available tools/forms within that category.

CDC Infection Control Self-Assessment Tools

CDC Hospital IC Worksheet 2016

CDC Long Term Care IC Worksheet 2016

CDC Dialysis IC Worksheet 2017

CDC Outpatient IC Worksheet 2016

CMS Audit Tools

CMS Audit of Practice Tools

Dental Healthcare Setting Tools

Infection Prevention Checklist for Dental Settings: Basic Expectations for Safe Care

Infection Control Considerations for Dental Services in Sites Using Portable Equipment or Mobile Vans

Ambulatory Surgical Center Infection Control Surveyor Worksheet

Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program

Precious Drugs & Scary Bugs: Antibiotic Stewardship Toolkit for Dental Providers November 2017

Dental Healthcare Infection Control Training Modules (CDC)

MODULE 1 —Introduction; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 2 – Hand Hygiene; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 3 – Personal Protective Equipment; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 4 – Respiratory Hygiene/Cough Etiquette; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 5 – Sharps Safety; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 6 – Safe Injection Practice; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 7 – Sterilization and Disinfection of Patient-Care Items and Devices; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 8 – Environmental Infection Prevention and Control; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 9 – Dental Unit Water Quality; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

MODULE 10 – Program Evaluation; IC in Dental Settings – Basic Expectations for Safe Care Training Modules

Device Disinfection/Sterilization

CIdex OPA Competency Checklist

Essential Elements of a Reprocessing Program for Flexible Endoscopes – Recommendations of the HICPAC

Sterilizer Maintenance Log (This form should be adapted to fit your facility’s needs and manufacturer’s instructions for use of the sterilizers)

Sterilizer Load Log (This form should be adapted to fit your facility’s needs and manufacturer’s instructions for use of the sterilizers)

Sterilizer Test Record (This form should be adapted to fit your facility’s needs and manufacturer’s instructions for use of the sterilizers)

Environmental Cleaning and Disinfection

Nebraska ICAP Environmental Cleaning Videos

NE ICAP EVS Audit Planning Worksheet: Acute Care

NE ICAP EVS Audit Planning Worksheet: Long-Term Care

NE ICAP EVS Cleaning Audit Assignment Worksheet: Long-Term Care

NE ICAP EVS Cleaning Audit Assignment Worksheet: Acute Care

NE ICAP OR EVS Audit Tracking

NE ICAP Patient Room EVS Audit Tracking Form

NE ICAP Public Area/ Public Restroom EVS Audit Tracking Form

NE ICAP Spa Shower EVS Audit Tracking Form

Annual Blacklight Tracking Workbook (Access fillable file by opening in Google Chrome)

AORN Environmental Cleaning Resources

CDC Environmental Cleaning Checklist

Environmental Rounding

APIC Environmental Rounds Worksheet

AORN Sample Cleaning checklist (General)

AORN Sample Enhanced Cleaning checklist

AORN Sample Cleaning Checklist Sterile Processing Dept.

CMS Hospital Infection Control Worksheet: Audit Tools

Hand Hygiene

ICAP Hand Hygiene Monitoring in Hospitals

ICAP Hand Hygiene Monitoring in LTC

NCSPICE Hand Hygiene Competency NCSPICE

Hand Hygiene Audit Tool Adapted from WHO

ASC Quality Collaboration on CMS Hand Hygiene

Infection Control Committee resource

Sample Agenda for an Infection Control Committee Meeting

Infection Surveillance

Culture Based Surveillance Algorithm 5.2019

Injection Safety

ICAP Blood Glucose Monitoring Audit Tool

Virginia Dept. of Health Administrator’s Checklist for Safe BGM

ICAP Injectable Medication Administration checklist

NC SPICE Injection Safety Competency Tool

Long Term Care Illness Logs and Tracking

Virginia General Illness Log

Virginia Monthly Infections Tracking Sheet

Medication Administration

ASHP Advantage Insulin Pen Storage and Labeling Audit

Observation Tools to Download

CDC Quick Observational Tools, provided through APIC’s website

Personal Protective Equipment

NC SPICE PPE Competency

Winnipeg Regional Health Authority PPE Audit Checklist

Refrigerator Temperature Log

Immunization Action Coalition Vaccine Refrigerator Temperature Log

Risk Assessment for Long-Term Care Facilities

NC SPICE Risk Assessment Template for LTC

Staff audits

IP Training Competency Audit Tool LTCF

IP Training Competency Audit Tool Acute Care

Surveillance

Culture Based Surveillance Algorithm

Transfer Form

CDC Interfacility Transfer Form

Interfacility Infection Control Transfer Form

Visitor Screening

ICAP Pediatric Services Sibling/Visitor Health Screen

If you are unable to find a resource on our website, please feel free to contact us by emailing subeach@nebraskamed.com . We will try to help you in finding that resource and if possible make it available on our website for others.

Page last reviewed: May 30, 2019