JIT Coach

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JIT Coach Survey

* Indicates required field

Coach Name *

Was this observed during rounds *

Yes No

What was the role of the health care professional you observed? *

RN = Nurse NA = Nursing Assistant MD = Doctor RT = Respiratory Therapy PT = Physical Therapy Diet = Dietary Technician Lab = Lab Technician HSK = House Keeping CM/SW = Case Mgmt/Social Worker Pharm = Pharmacist Rad = Radiology Tech Other

If other please specify their role: *

Was it an entry or an exit? *

Entry Exit

Did the person wash? *

Yes No

Possible contributing factors to not washing *

Dispenser Location Dispenser Empty Dispenser Broken Equipment Shared Hands Full of Supplies Hands Full of Meds Improper Use of Gloves Follow Person Entry or Exit Frequent Entry or Exit Admissions or Discharges Process Lack of Immediate Feedback Distracted or Forgot Perception that HH is not Required Perception of Skin Irritation Other

If other please specify: *

Comments: *

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