Sample General Area Cleaning Checklist

As part of Lakeland (Fla.) Surgical & Diagnostic Center's efforts to prevent infections and comply with regulatory and reporting requirements, the ASC documents when its general areas are cleaned by the service it employs to perform the cleaning.


The ASC requires the cleaner to initial a checklist form indicating when each of 16 cleaning tasks are completed. These tasks includes scrubbing and cleaning sinks and counters, sweeping and mopping throughout the facility, and removal of trash and recycling


The surgery center also has a member of its staff confirm that each of the tasks were completed and pass inspection by initialing in a separate area on the form.


To download a sample copy of the general area cleaning checklist you can adapt for use in your ASC, click here (doc). To download a Spanish version of this checklist, click here (doc).


Learn more about Lakeland Surgical & Diagnostic Center.

Download other sample forms for adaptation and use in your ASC:


- Sample Medication Reconciliation Form


- Sample ASC Adult PONV/PDNV Policy


- Sample ASC Time-Out Policy and Procedure

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