* 1. Please enter your Employee ID Number.

* 2. Unit observed for hand hygiene:

* 3. Case Manager

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 4. Dietition

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 5. Environmental Services (EVS)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 6. Health Care Technician (HCT/UST/MOA)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 7. Licensed Practical Nurse (LPN)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 8. Medical Student

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 9. Nurse Practitioner

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 10. Nursing Student

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 11. Occupational Therapist (OT)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 12. Physical Therapist (PT)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 13. Physician

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 14. Physician's Assistant (PA)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 15. PICC Team

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 16. Radiology Tech (RT)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 17. Recreational / Speech Therapist

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 18. Registered Nurse (RN)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 19. Respiratory Therapist (RRT)

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 20. Social Worker

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 21. Spiritual Care

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 22. Tray Passer

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 23. Transporter

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

* 24. Volunteer

  1 2 3 4 5
Hand Hygiene- YES
Hand Hygiene- NO
(Did Not Intervene)
Hand Hygiene- NO (Intervened)

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