Checklist

THE IPC FORMS TOOLKIT

Welcome to the IPC Forms Toolkit!

Check below for templates, observation tools, risk assessments, and more that you can use to develop or enhance your own program!

 

PROGRAM & RISK ASSESSMENT

CDC

ACUTE CARE

"This tool is intended to assist in the assessment of infection control programs and practices in acute care hospitals. If feasible, direct observations of infection control practices are encouraged. To facilitate the assessment, health departments are encouraged to share this tool with hospitals in advance of their visit."

CDC

LONG-TERM CARE

"This tool is intended to assist in the assessment of infection control programs and practices in nursing homes and other long-term care facilities. If feasible, direct observations of infection control practices are encouraged. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit."

CDC

OUTPATIENT

"This tool is intended to assist in the assessment of infection control programs and practices in outpatient settings. In order to complete the assessment, direct observation of infection control practices will be necessary. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit."

CDC

HEMODIALYSIS FACILITY

"This tool is intended to assist in the assessment of infection control programs and practices in dialysis facilities. In order to complete the assessment, direct observation of infection control practices will be necessary. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit."

APIC

AMBULATORY FACILITY RISK ASSESSMENT TOOL

"This Risk Assessment tool, beginning on page 6, can be used to conduct a facility risk assessment for acquiring and transmitting infections in a variety of ambulatory healthcare settings.

APIC

FACILITY RISK ASSESSMENT TOOL

A general facility risk assessment template

CDC

MINIMUM EXPECTATIONS FOR SAFE CARE (OUTPATIENT)

CDC's minimum expectations for safe care

CDC

CORRECTIONS FACILITY (COVID)

"This tool can help state and local health departments provide technical assistance to correctional and detention facilities during the COVID-19 pandemic. Each question in this document is intended to initiate discussion between the health department interviewer and facility representative(s) about a specific part of CDC’s guidance for correctional and detention facilities. Some questions have discrete response options while other are open-ended.

 
Laptop

APIC'S IMPLEMENTATION GUIDES

"APIC Implementation Guides provide practical, evidence-based strategies for surveillance and the elimination of infection. Each guide includes online tools and resources."

Guides Include topics on:

  • Operating Room/Peri-op

  • CLABSI and CAUTI Prevention

  • CDiff Prevention

  • MRSA Prevention (Acute and Long-term Care)

  • SSI Prevention (Ortho and CABG)

  • Hemodialysis

  • Hand Hygiene

  • And more!

 

MDRO ASSESSMENT AND PREVENTION

CDC

MDRO ACTIVITY ASSESSMENT TOOL

"This form can be used to assess the program in place in acute care hospitals to control transmission of multidrug-resistant organisms (MDROs)."

 

ENVIRONMENT OF CARE

Cleaning, Disinfection, Sterilization, Injection Safety, Standard and Transmission-based Precaution, etc.

CDC

ENVIRONMENTAL CHECKLIST FOR MONITORING TERMINAL CLEANING

CDC

ENVIRONMENTAL CLEANING EVALUATION WORKSHEET

CDC

RISK ASSESSMENT FOR DETERMINING CLEANING FREQUENCY

CDC

WATER MANAGEMENT TOOLKIT

APIC/CDC

HIGH LEVEL DISINFECTION AUDIT TOOLKIT

APIC/CDC

INJECTION SAFETY AUDIT TOOLKIT

APIC/CDC

STANDARD PRECAUTIONS AUDIT BUNDLE

APIC/CDC

TRANSMISSION -BASED PRECAUTIONS AUDIT BUNDLE

CDC

TRANSMISSION-BASED PRECAUTIONS (SIGNS)

CDC

ENHANCED BARRIER PRECAUTIONS (SIGN)

 

CONSTRUCTION

ASHE

INFECTION CONTROL RISK ASSESSMENT (ICRA) DURING CONSTRUCTION AND RENOVATION

Example of ICRA form provided by the American Society for Healthcare Engineering (ASHE)

 

DEVICE RELATED INFECTION PREVENTION

CAUTI, CLABSI, and VAP/VAE

CDC

CAUTI FACILITY ASSESSMENT

CDC

CLABSI FACILITY ASSESSMENT

APIC/CDC

URINARY CATHETER BUNDLE

APIC/CDC

CENTRAL LINE BUNDLE

APIC/CDC

VENTILATOR OBSERVATION BUNDLE

 

DIALYSIS

CDC

DIALYSIS STATION DISINFECTION AUDIT TOOL

CDC

HD CONNECT/DISCONNECT AUDIT TOOL

CDC

CATHETER EXIT SITE CARE AUDIT TOOL

CDC

AV FISTULA & GRAFT DE/CANNULATION AUDIT TOOL

CDC

HD INJECTABLE MEDICATION AUDIT TOOL

CDC

HD HAND HYGIENE OBSERVATIONS

 

DATA COLLECTION

APIC

DATA TABULATION EXCEL SPREADSHEET

"The Microsoft Excel™ spreadsheet available for download includes 12 tabs (labeled T1-T12) for data entry of summary observations for 12 time periods (e.g., one per month) covering all 123 questions found on all 22 observation tools (see example here)"