Form 10-xxxx Patient Centered Hand Hygiene Survey Form

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCA, VBA, VHA)

Patient centered HH survey form

Patient Centered Hand Hygiene Survey

OMB: 2900-0770

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Infection Prevention

It’s in your Hands



Please help us provide the best care possible by being involved with Your Care!


  • Using soap & water or alcohol rubs is one of the ways that helps us to prevent the spread of germs.


  • Please observe our healthcare providers and staff to see they wash their hands or use the alcohol rub before providing your care.


  • Take an active part in your care by completing this survey and placing it in the receptacle in the reception area or by returning it to the person who gave it to you.










Clinic/Unit:__________________________


Date:______________________________



Healthcare worker Performed hand hygiene?

Physician □Yes □No

Nurse □Yes □No

Other □Yes □No



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMichael Raczynski
File Modified0000-00-00
File Created2021-01-20

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