Enhanced Cleaning Request

Name *

Email Address *

Room Number *

Site Name *

Reason for the request: *

Before the request is logged as a new job the following has to have been carried out. Have the nursing team carried out the following?

Decontamination of all medical equipment in the room. *

Bed/plinth Desk Drugs trolley/Cabinet Chairs

Please attach a copy/photograph of the Nursing cleaning register with evidence of cleaning having taken place. *

Has the room been placed out of use/awaiting cleaning. *

Yes No

Please ensure that you have also logged the request into your site cleaning communications book - Thank you.

To report an issue with a form email us at
web@ecchcic.nhs.uk