Paris Community Hospital/Family Medical Center
Hand Hygiene and Isolation Precautions Observation Form
Department/Unit Observing: ______________________
Initials:___________
Date: ___________ Time of day: ____________AM/PM to ____________AM/PM
Instructions: Complete the above section. You are asked to conduct 5 “Secret Shopper”
observations. In the gray area, please identify the type of worker you are observing using the
codes below. If “12 – Other” is used, please write in the type of worker. In the sections below
worker type, mark Y, N, or N/A to answer whether the appropriate hand hygiene and/or isolation
precautions (PPE-personal protective equipment) was used at that time. If a non-compliance is
witnessed, please write the name of the person in the blank. Please return all completed forms
to your manager. The observer’s name will remain anonymous.
Health Care worker Type:
1 = Physician
7= Housekeeping
Y = Yes
2 = CRNA/NP
8 = Maintenance
N = No
3 = Nurse
9 = Dietary
N/A = Not Applicable
4 = CNA/CMA
10 = Lab
5 = Respiratory
11 = Radiology
6 = Physical Therapy 12 = Other (Write In)
Worker Type: Please
enter worker type
here.
Upon Entering Room/
Before Patient Contact
Gloves Appropriately
Used
Upon Exiting Room/ After
Patient Contact
If a patient is in Isolation
Precautions, was
appropriate PPE used
Type of Isolation
Precautions(Contact/Droplet/Airborne)
Name of Person NonCompliant
Other Observations noted: Chipped nail polish, Artificial nails, Lack of hand hygiene supplies,
washing less than 15 seconds, etc.
____________________________________________________________________________
____________________________________________________________________________
Isolation Precautions
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Contact Isolation



Contact Isolation for
C Diff




Droplet Isolation




Airborne Isolation




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Always Wear gloves when entering room and
when touching patient’s intact skin, surfaces,
or articles in close proximity
Always wear gown when entering room and
whenever anticipating that clothing will touch
patient items or potentially contaminated
environment
Use patient-dedicated or single-use
disposable shared equipment or clean and
disinfect shared equipment between patients
DO NOT USE FOAM OR OTHER HAND
DISINFECTANT IN PLACE OF SOAP &
WATER
Always Wear gloves when entering room and
when touching patient’s intact skin, surfaces,
or articles in close proximity
Always wear gown when entering room and
whenever anticipating that clothing will touch
patient items or potentially contaminated
environment
Use patient-dedicated or single-use
disposable shared equipment or clean and
disinfect shared equipment between patients
Always wear an Mask when working within
three feet of the patient
Wear eye protection when performing
procedures that could induce sneezing or
coughing
Always Wear gloves when entering room and
when touching patient’s intact skin, surfaces,
or articles in close proximity
Always wear gown when entering room and
whenever anticipating that clothing will touch
patient items or potentially contaminated
environment
Use patient-dedicated or single-use
disposable shared equipment or clean and
disinfect shared equipment between patients
Wear N95 respirator when entering room
Keep door closed
Always Wear gloves when entering room and
when touching patient’s intact skin, surfaces,
or articles in close proximity
Always wear gown when entering room and
whenever anticipating that clothing will touch
patient items or potentially contaminated
environment
Use patient-dedicated or single-use
disposable shared equipment or clean and
disinfect shared equipment between patients
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