Anda di halaman 1dari 10

SURVEY KEBERSIHAN KAMAR MANDI

INSTALASI SANITASI RUMAH SAKIT SURYA ASIH


No : ...........................................
Lokasi : ...........................................
Hari & Tanggal : ...........................................

Nama Ruang
No Variabel
Baik Tidak Baik Tidak Baik Tidak
A. Kualitas Kebersihan KM/WC

1. Lantai tdk kotor & tidak licin


2. Sudut lantai tdk kotor & tidak bernoda
3. Dinding tdk bernoda & tidak berlawa
4. Langit tdk bernoda & tidak berlawa
5. Bak air tdk kotor & tidak ada jentik
6. Gayung air tdk kotor & tidak licin
7. Daun pintu tdk kotor & tidak bernoda
8. Closed tdk kotor, tidak bernoda
9. Saringan floordrain terpasang dg baik
10. Lampu tdk kotor & tdk berdebu
11. Exhaustfan tidak kotor
12. Terdapat tempat sampah
13. Penempatan barang rapi
14. Kusen&kaca ventilasi tdk ktr&tdk berdebu
C. Kualitas Wastafel

1. Tidak licin

2. Tidak bernoda

3. Tidak berkerak

4. Bagian bawah bersih & tdk berlawa

5. Tidak berbau
Catatan - catatan :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

Petugas

( ...........
SURVEY KEBERSIHAN RUANG
INSTALASI SANITASI RUMAH SAKIT SURYA ASIH
No : ...........................................
Lokasi : ...........................................
Hari & Tanggal : ...........................................

Nama Ruang
No Variabel
Baik Tidak Baik Tidak Baik Tidak
A. Kebersihan & Kerapihan Ruang
1. Lantai tdk ada kotoran & tdk bernoda
2. Sudut lantai tdk ada kotoran&tdk bernoda
3. Dinding tdk berdebu,tdk bernoda,tdk berlawa
4. Batas antara dinding keramik dg tembok tdk
ada kotoran & tdk berdebu
5. Langit tdk bernoda & tdk berlawa
6. Kaca jendela tdk kotor,tdk berdebu&tdk bernoda
7. Kaca ventilasi tdk kotor,tdk berdebu&tdk bernoda
8. Kusen jendela & pintu tdk berdebu
9. Daun pintu tdk bernoda & tdk berdebu
10. Mebelair (meja,kursi,bed cermin) tdk kotor
& tdk berdebu
11. Mebelair tertata rapi
12. AC/kipas tdk kotor & tdk berdebu
13. Atas kap lampu, panel instrument/listrik tdk
kotor tdk berdebu
14. Sayap gedung/teras ruangan tdk kotor
15. Melakukan desinfeksi permukaan (lantai,
dinding , bed & mebelair lainnya tiap hari)

B. Kualitas Wastafel
1. Tidak licin
2. Tidak bernoda
3. Tidak berkerak
4. Bagian bawah bersih & tdk berlawa
5. Tidak berbau

C. Keberadaan Serangga & Binatang Pengganggu


1. Tidak ada jentik
2. Tidak ada kecoa
3. Tidak ada tikus
4. Tidak ada serangga/binatang lain

D. Kualitas SDM Cleaning Service


1. Hand hygiene sesuai prosedur
2. Mengetahui jenis & dosis desinfektan
3. Penanganan tumpahan prosedur
Catatan - catatan :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

Petugas

( ...........
.
.
.

uang

Baik Tidak Baik Tidak

......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................

etugas RS. SURYA ASIH

.....................................)
uang

Baik Tidak Baik Tidak


......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................

etugas RS. SURYA ASIH

.....................................)
SURVEY KEBERSIHAN SAMPAH MEDIS & NON MEDIS
INSTALASI SANITASI RUMAH SAKIT SURYA ASIH
No : ...........................................
Lokasi : ...........................................
Hari & Tanggal : ...........................................

Nama Ruang
No Variabel
Baik Tidak Baik Tidak Baik Tidak
A. Pengelolaan Sampah Non Medis

1. Tersedianya fasilitas bak sampah


2. Bak sampah sesuai standar & berlabel
3. Ada kantong plastik pelapis yang sesuai (hitam)
4. Sampah tidak tercampur(sesuai antara jenis
sampah dengan bak sampahnya
5 Bak dan tutup bak tidak kotor
6 Lingkungan sekitar bak tidak kotor

B. Pengelolaan Sampah Medis

1. Tersedianya fasilitas bak sampah


2. Bak sampah sesuai standar & berlabel
- Untuk troly (ember)
- Untuk ruangan (model injak)
- Untuk tempat penampungan besar ( model injak)

3. Ada kantong plastik pelapis yang sesuai (kuning)

4. Sampah tidak tercampur (sesuai antara jenis

sampah dengan bak sampahnya)

5. Bak dan tutup bak tidak kotor

6. Lingkungan sekitar bak tidak kotor

7. Tersedia fasilitas penampung plabot dengan

kantong plastik pelapis kuning

8 Tersedia fasilitas penampung botol/vial

dengan kantong pelapis kuning.


Catatan - catatan :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

Mengetahui
Ka BSL/Unit/Bag/Poli Petugas
( .....................................) ( ...........
IS

.
.
.

uang

Baik Tidak Baik Tidak

......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................

etugas RS. SURYA ASIH


.....................................)