Form 0917-0036 Hand Washing Survey

Do not know

No

Our facility strives to provide the best patient care during your visit,
which includes ways to limit the spread of germs. Please take a
moment to complete these questions about your health care visit today.

Yes

Patient Assessment of Health Care Staff Hand Washing/ Hand Gel Use

Does not apply

Survey Month: __________

Form Approved
OMB Form No. 0917-0036
Expiration Date: _______

1. Did you see the health care staff either wash their hands or use hand gel

BEFORE providing care to you?
2. Did you see the health care staff either wash their hands/use hand gel
AFTER providing care to you?
3. If the health care staff wore gloves, did you see them wash their
hands/use hand gel AFTER removing the gloves?

Please return form to the appointment desk or place in a suggestion box when completed.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time required
to complete this information collection is estimated to average less than 10 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health
Service, OMS/DRA, Mail Stop: 09E70, 5600 Fishers Lane, Rockville, MD 20857 ATTN: Information Collections Clearance Officer.

Do not know

No

Our facility strives to provide the best patient care during your visit,
which includes ways to limit the spread of germs. Please take a
moment to complete these questions about your health care visit today.

Yes

Patient Assessment of Health Care Staff Hand Washing/ Hand Gel Use

Does not apply

Survey Month: __________

Form Approved
OMB Form No. 0917-0036
Expiration Date: _______

1. Did you see the health care staff either wash their hands or use hand gel

BEFORE providing care to you?
2. Did you see the health care staff either wash their hands/use hand gel
AFTER providing care to you?
3. If the health care staff wore gloves, did you see them wash their
hands/use hand gel AFTER removing the gloves?

Please return form to the appointment desk or place in a suggestion box when completed.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. The time required
to complete this information collection is estimated to average less than 10 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health
Service, OMS/DRA, Mail Stop: 09E70, 5600 Fishers Lane, Rockville, MD 20857 ATTN: Information Collections Clearance Officer.