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* 1. Please enter your Employee ID Number.

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* 2. Area observed for hand hygiene:

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* 3. Anes/CRNA

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

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* 4. Environmental Services (EVS)

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

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

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

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* 6. Lab Technician

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

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* 7. Licensed Practical Nurse (LPN)

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

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* 8. Medical Student

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

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* 9. Nurse Practitioner

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

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* 10. Nursing Student

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

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* 11. Physical /Occupational/ Recreational / Speech Therapist

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

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* 12. Physician

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

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* 13. Physician's Assistant (PA)

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

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* 14. Radiology Tech (RT)

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

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* 15. Registered Nurse (RN)

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

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* 16. Respiratory Therapist (RRT)

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

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* 17. Social Worker

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

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* 18. Transporter/Peri-Op

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

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