![](media/image1.wmf)

**SUPPLY, PROCESSING, AND DISTRIBUTION (SPD)**

# **CONTENTS**

Page

## SECTION -- A

SPD --
General........................................................................................**1
-- 4**

## SECTION -- B

Distribution.............................................................................................**5
-- 8**

## SECTION -- C

Case
Carts.............................................................................................**9**

## SECTION - D

Preparation............................................................................................**10-12**

## SECTION -- E

Decontamination.....................................................................................**13-14**

### INTRODUCTION

This guide is to be used to evaluate the over all performance of the
Supply, Processing, and Distribution (SPD) section. This guide should be
used at least every 6 months, and it should be completed by someone out
side of the SPD section. This guide is divided into five sections,
including some of which may not apply to your SPD area. If a section
does not apply, a full explanation as to why the support is not being
provided and who is performing the function should be given for that
section of the guide to completed.

The findings of this evaluation should be shared with the infection
control official and other appropriate officials at the medical center.

+-----------------------------------+----+----+------------------------+
| ##### SPD - GENERAL               |    |    |                        |
+===================================+====+====+========================+
|                                   | ## | #  | ###### Comments        |
|                                   | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   |  Y | #  |                        |
|                                   | es | No |                        |
+-----------------------------------+----+----+------------------------+
| 1\. Is the SPD Desk Guide         |    |    | \_\_\_                 |
| complete and in use? **Ref. VA    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Directive 7176, 2. (a.) (b.)**    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| a\. The SPD Desk Guide was        |    |    | \_\_\_                 |
| reviewed within the last 12       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| months by:                        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
| > \(1\) Chief, SPD                |    |    | \_\_\_                 |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > \(2\) Service Chief             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > \(3\) Infection Control         |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Does the SPD Desk Guide     |    |    | \_\_\_                 |
| > have a current organization     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > chart? **Ref. VA Handbook 7176  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 1. 2. 102**                |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > c\. Are the SPD department      |    |    | \_\_\_                 |
| > hours of operation listed?      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part 1. |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 5. 104 d. (see NOTE)**          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > d\. Is there a list of personal |    |    | \_\_\_                 |
| > authorized access to SPD after  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > hours? **Ref. VA Handbook 7176  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 1. 5. 104 d. (see NOTE)**  |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > e\. Are there procedures for    |    |    | \_\_\_                 |
| > record of entry and sign out of |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > supplies? **Ref. VA Handbook    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 7176 Part 1. 5. 104 d**         |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > f\. Is there a list of          |    |    | \_\_\_                 |
| > employees to contact in an      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > emergency?                      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > g\. Is there a floor plan of    |    |    | \_\_\_                 |
| > the department with the work,   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > air, and people flow indicated? |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part 3. |    |    |                        |
| > 10. 310 a,c,d. (see example     |    |    |                        |
| > Level 1 Training Manual TP 90-2 |    |    |                        |
| > page 122)**                     |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > h\. Is there policy on the      |    |    | \_\_\_                 |
| > frequency, methods, and levels  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > of the station EtO monitoring?  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part 5. |    |    |                        |
| > 4. 504. 1,2,3.**                |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > i\. Is there a disaster plan    |    |    | \_\_\_                 |
| > for the SPD staff in Section 5  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > of the SPD Desk Guide? **Ref.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > VA Handbook 7176 Part 5. 2.     |    |    |                        |
| > 502**                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > j\. Is there a fire plan for    |    |    | \_\_\_                 |
| > the SPD staff in Section 6 of   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > the SPD Desk Guide? **Ref. VA   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 5. 1. 501**  |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > k\. In Section 7 of the SPD     |    |    | \_\_\_                 |
| > Desk Guide, is there a hazard   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > communication plan for the SPD  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > staff, including but not        |    |    |                        |
| > limited to: **Ref. VA Handbook  |    |    | \_\_\_                 |
| > 7176 Part 5. 504.9,13,16        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > a,b,c**                         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > \(1\) EtO Leak/Spill/Exposure?  |    |    | \_\_\_                 |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > \(2\) Mercury Spill?            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > \(3\) Antineoplastic Drug       |    |    |                        |
| > Spill?                          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > l\. In Section 8 of the SPD     |    |    | \_\_\_                 |
| > Desk Guide, are all of the      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > equipment operation             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > instructions for SPD equipment  |    |    |                        |
| > accounted for? **Ref. VA        |    |    |                        |
| > Handbook Part 11. 3. 1103. 2c** |    |    |                        |
+-----------------------------------+----+----+------------------------+
| m\. Are there operating           |    |    | \_\_\_                 |
| procedures for each section of    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| SPD and each task, including but  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| not limited to: **Ref. VA         |    |    |                        |
| Handbook 7176**                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > \(1\) Ward Inventory? **Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 10.**                           |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > \(2\) Sterilizer? **Part 8.**   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > \(3\) Monitoring? **Part 8.**   |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > \(4\) Decontamination Pick-up?  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Part 6.**                     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > \(5\) Pulling Case Cart? **Part |    |    | \_\_\_                 |
| > 9.**                            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > n\. In Section 10 of the SPD    |    |    | \_\_\_                 |
| > Desk Guide, is there a list of  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > the Material Safety Data        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Sheets, with their locations?   |    |    |                        |
| > **Ref. VA Handbook 7176 Part 5. |    |    |                        |
| > 4. 504. 14a,b.**                |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > o\. In Section 11 of the SPD    |    |    | \_\_\_                 |
| > Desk Guide, are there completed |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > sample forms such as CA-1,      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > CA-2, and leave request forms   |    |    |                        |
| > that the SPD staff may be       |    |    |                        |
| > required to use? **Ref. VA      |    |    |                        |
| > Handbook 7176 Part 5.           |    |    |                        |
| > 3.503a,b.**                     |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > p\. In Section 12 of the SPD    |    |    | \_\_\_                 |
| > Desk Guide, is there a list of  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > items that are sterilized by    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > EtO or methods other than steam |    |    |                        |
| > sterilization? **Ref. VA        |    |    |                        |
| > Handbook 7176 Part 7. 3. 703 d. |    |    |                        |
| > (1)**                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > q\. Has the list been signed by |    |    | \_\_\_                 |
| > the Chief of Staff within the   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > last 12 months? **Ref.. VA      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 7. 3. 703 d. |    |    |                        |
| > (1)**                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 2\. Have all SPD staff reviewed   |    |    | \_\_\_                 |
| and signed the Employee Review    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Record (page VI of the SPD Desk   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Guide)?                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 3\. Is the Chief, SPD, a member   |    |    | \_\_\_                 |
| of the Infection Control          |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Committee? If not, why? **Ref. VA |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Handbook 7176 Part 1. 3. 103      |    |    |                        |
| b.4a**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 4\. Are all of the SPD staff      |    |    | \_\_\_                 |
| certified by the VACO             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| certification program? If not     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| why?                              |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. What is the schedule for    | \_ |    |                        |
| > completion of the certification | \_ |    |                        |
| > program? **Ref. VA Handbook     | \_ |    |                        |
| > 7176 Part 2. 1. 201 a, b**      | \_ |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > b\. Has Level 1 of the training |    |    | \_\_\_                 |
| > been completed? If not, what    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > documentation is available to   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > show that the staff is          |    |    |                        |
| > qualified to perform their      |    |    |                        |
| > duties? **Ref. VA Handbook 7176 |    |    |                        |
| > Part 2. 2. 202 d**              |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > c\. Is there a training record  |    |    | \_\_\_                 |
| > for each staff member? **Ref.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > VA Handbook 7176 Part 2. 202    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > d.**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > d\. Has the SPD staff attended  |    |    | \_\_\_                 |
| > at least 12 SPD in-service      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > training sessions within the    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > last 12 months? **Ref. VA       |    |    |                        |
| > Handbook 7176 Part 2. 2. 202.** |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 5\. Is SPD doing all of the       |    |    |                        |
| decontamination and sterilization |    |    |                        |
| of reusable medical/surgical      |    |    |                        |
| devices in the medical center? If |    |    |                        |
| not, why?                         |    |    |                        |
+-----------------------------------+----+----+------------------------+
| a\. Decontamination: **Ref. VA    |    |    | \_\_\_                 |
| Handbook 7176 Part 6. 1. 601b**   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Dental?                         |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Surgery?                        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Wards?                          |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Outpatient Clinics?             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > G.I. Lab?                       |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Catherization Lab?              |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Pharmacy?                       |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Respiratory Therapy?            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Radiology?                      |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| b\. Sterilization: **Ref. VA      |    |    | \_\_\_                 |
| Handbook 7176 Part 8. 9. 809 a.** |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Dental?                         |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Surgery?                        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Wards?                          |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Outpatient Clinics?             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > G.I. Lab?                       |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Catherization Lab?              |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Pharmacy?                       |    |    |                        |
| >                                 |    |    | \_\_\_                 |
| > Respiratory Therapy?            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Radiology?                      |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 6\. Does SPD provide inventory    |    |    | \_\_\_                 |
| management support including      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| ordering, stocking, and           |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| distribution for all of the areas |    |    |                        |
| listed in question 5 above? if    |    |    |                        |
| not, which areas are not being    |    |    |                        |
| supported and why? **Ref. VA      |    |    |                        |
| Handbook 7176 Part 1. 1. 101      |    |    |                        |
| a,b,c.**                          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 7\. Visit a representative from   |    |    | \_\_\_                 |
| each of the services supported by |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| SPD to see if any inventory       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| management, decontamination, and  |    |    |                        |
| sterilization is being done in    |    |    | \_\_\_                 |
| the service. If so, who is doing  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| that function and why?            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 8\. Review their areas and        |    |    |                        |
| procedures in accordance with the |    |    |                        |
| applicable section of this SPD    |    |    |                        |
| Desk Guide i.e., the              |    |    |                        |
| decontamination section will need |    |    |                        |
| to be filled out for those        |    |    |                        |
| services doing decontamination,   |    |    |                        |
| and the preparation section will  |    |    |                        |
| need to be filled out for those   |    |    |                        |
| services doing sterilization.     |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Are the soiled and clean    |    |    | \_\_\_                 |
| > areas completely separated      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > (walls)? **Ref. VA Handbook     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 7176 Part 3. 9. 309**           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. How often is SPD cleaned?   | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part 3. | \_ |    |                        |
| > 12. 312 a,b,c.**                | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > c\. Which area of SPD is        | \_ |    |                        |
| > cleaned first? **Ref. VA        | \_ |    |                        |
| > Handbook 7176 Part 6. 4. 604    | \_ |    |                        |
| > g.**                            | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > d\. What method is used in each | \_ |    |                        |
| > area? **Ref. VA Handbook 7176   | \_ |    |                        |
| > Part 6. 4. 604 g.**             | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+

+-----------------------------------+----+----+------------------------+
| ##### DISTRIBUTION                |    |    |                        |
|                                   |    |    |                        |
| ######                            |    |    |                        |
+===================================+====+====+========================+
|                                   | ## | #  | ###### Comments        |
|                                   | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   |  Y | #  |                        |
|                                   | es | No |                        |
+-----------------------------------+----+----+------------------------+
| 1\. Are there three sections:     |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Bulk storage?                     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
| > Primary stock?                  |    |    | \_\_\_                 |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Secondary stock?                |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > a\. **[Bulk                     |    |    |                        |
| > Storage]{.underline}**          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(1\) Bulk storage with a       |    |    | \_\_\_                 |
| > receiving and break out area?   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 10. 4. 1004 b.**                |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(2\) No open cases with        |    |    | \_\_\_                 |
| > clean/sterile supplies are to   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > be in this area. Were open      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > cases found? **Ref. VA Handbook |    |    |                        |
| > 7176 Part 10. 4. 1004 b.**      |    |    |                        |
+-----------------------------------+----+----+------------------------+
| (3) How is the stock arranged?    |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Is it rotated? **Ref. VA        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 10. 2. 1002  |    |    |                        |
| > h.**                            |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(4\) How many days supply is   | \_ |    |                        |
| > on hand:                        | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(a\) Posted stock? **Ref. VA   | \_ |    |                        |
| > Handbook 7176 Part 4. 2. 402    | \_ |    |                        |
| > a.**                            | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(b\) Open market? **Ref. VA    | \_ |    |                        |
| > Handbook 7176 Part 4. 2. 402    | \_ |    |                        |
| > b.**                            | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(c\) Prime vendor? **Ref. VA   | \_ |    |                        |
| > Handbook 7176 Part 10. 2. 1002. | \_ |    |                        |
| > f 2**                           | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   |    |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   |    |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. **[Primary                  |    |    |                        |
| > Stock]{.underline}**            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(1\) Is this a limited access  |    |    | \_\_\_                 |
| > area? **Ref. VA Handbook 7176   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 10. 3. 1003 g.**           |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(2\) What is the dress attire? | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part    | \_ |    |                        |
| > 9. 1. 901 a.**                  | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(3\) Does the dress attire     |    |    | \_\_\_                 |
| > differ from the rest of SPD?    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 9. 1. 901 a.**                  |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > c\. Are there any shipping or   |    |    | \_\_\_                 |
| > corrugated boxes in this area?  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > If yes, list the items. **Ref.  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > VA Handbook 7176 Part 10. 3.    |    |    |                        |
| > 1003 e.**                       |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > d\. Is this area clean? **Ref.  |    |    | \_\_\_                 |
| > VA Handbook 7176 Part 10. 3.    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 1003 a.**                       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > e\. How often is it cleaned?    | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part 3. | \_ |    |                        |
| > 12. 312 a,b.**                  | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > f\. Check every tenth line item | \_ |    |                        |
| > to see if there are outdates    | \_ |    |                        |
| > and if the supplies are being   | \_ |    |                        |
| > rotated.                        | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| g.  How are the items transported | \_ |    |                        |
|     to the secondary from the     | \_ |    |                        |
|     primary: **Ref. VA Handbook   | \_ |    |                        |
|     7176 Part 9. 1. 901 c.**      | \_ |    |                        |
|                                   | \_ |    |                        |
| > \(1\) Regular issue?            | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(2\) Single issue?             | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(3\) Emergencies?              | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(4\) Pick up items by user?    | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 2\. What is the primary inventory | #  | #  | ######                 |
| system used to stock the          | ## | ## |                        |
| secondaries from the primary:     | ## | ## |                        |
| **Ref. VA Handbook 7176 Part 10.  | #  | #  |                        |
| 2. 1002 b, e**                    |    |    |                        |
+-----------------------------------+----+----+------------------------+
| a\. Demand? **Ref. VA Handbook    |    |    | \_\_\_                 |
| 7176 Part 9. 2. 902 1 a, b.**     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| (1) How are the supplies ordered  |    |    |                        |
|     :                             |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > telephone by users              |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > computer systems,               |    |    | \_\_\_                 |
| >                                 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > at window?                      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| >                                 |    |    |                        |
| > **Ref. Va Handbook 7176 Part 9. |    |    |                        |
| > 2. 902 1a**                     |    |    |                        |
| >                                 |    |    |                        |
| > \(2\) Does SPD make deliveries? |    |    |                        |
| > If not, who makes them? **Ref.  |    |    |                        |
| > VA Handbook 7176 Part 9. 2. 902 |    |    |                        |
| > 1a**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| b\. Par Level? **Ref. VA Handbook |    |    | \_\_\_                 |
| 7176 Part 9. 2. 902 2 a-d**       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(1\) How often are inventories | \_ |    |                        |
| > performed? **Ref. VA Handbook   | \_ |    |                        |
| > 7176 Part 9. 2. 902 2a**        | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(2\) Are all secondaries       |    |    | \_\_\_                 |
| > inventoried at the same         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > intervals? If yes, why?         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Exchange Carts? **Ref. VA   |    |    | \_\_\_                 |
| > Handbook 7176 Part 9. 2. 902.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 3a & b**                        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(1\) When are they             | \_ |    |                        |
| > exchanged**? Ref. VA Handbook   | \_ |    |                        |
| > 7176 Part 9. 2. 902. 3a**       | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(2\) How often? **Ref. VA      | \_ |    |                        |
| > Handbook 7176 Part 9. 2. 902    | \_ |    |                        |
| > 3a**                            | \_ |    |                        |
| >                                 | \_ |    |                        |
| > \(3\) By whom? **Ref. VA        | \_ |    |                        |
| > Handbook 7176 Part 9. 2. 902    | \_ |    |                        |
| > 3a**                            | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 3\. What method is used to        |    |    |                        |
| deliver the med/surg supplies     |    |    |                        |
| from the primary to the           |    |    |                        |
| secondary: **Ref. VA Handbook     |    |    |                        |
| 7176 Part 9. 1. 901 c.**          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Carts? **Ref. VA Handbook   |    |    | \_\_\_                 |
| > 7176 Part 9. 3. 903**           |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(1\) Are they closed? If not,  |    |    | \_\_\_                 |
| > are the supplies in closed      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > containers that will not allow  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > the items to be crushed or      |    |    |                        |
| > damaged? **Ref. VA Handbook     |    |    |                        |
| > 7176 Part 9. 6. 906**           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(2\) If carts are open and a   |    |    | \_\_\_                 |
| > cover is used, is the bottom    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > shelf closed or solid? **Ref.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > VA Handbook 7176 Part 9. 6.     |    |    |                        |
| > 906**                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(3\) How often is the cover    | \_ |    |                        |
| > cleaned and/or changed? **Ref.  | \_ |    |                        |
| > VA Handbook 7176 Part 9. 6.     | \_ |    |                        |
| > 906**                           | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(4\) What are the covers made  | \_ |    |                        |
| > of? **Ref. VA Handbook 7176     | \_ |    |                        |
| > Part 6. 7. 607 b.**             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(5\) Are the covers impervious |    |    | \_\_\_                 |
| > to moisture and dust? **Ref. VA |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 9. 1. 901    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > c.**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. Dumbwaiter/Cartlifts?       |    |    | \_\_\_                 |
| > **Ref. VA Handbook 7176 Part 9. |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 3. 903**                        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(1\) Are they used for only    |    |    | \_\_\_                 |
| > clean items? **Ref. VA Handbook |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 7176 Part 6. 7. 607 d.**        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(2\) Are the supplies          |    |    | \_\_\_                 |
| > protected while in the          |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > dumbwaiter? **Ref. VA Handbook  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 7176 Part 9. 1. 901 c.**        |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > c\. Hand Delivery? If yes, how  |    |    | \_\_\_                 |
| > are the items protected? **Ref. |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > VA Handbook 7176 Part 9. 1. 901 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > c.**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 4\. Is the IFCAP/GIP system in    |    |    | \_\_\_                 |
| use? **Ref. VHA Handbook 1761.2   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Part 5. Requirements a-b.**       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > a\. For primary inventories?    |    |    | \_\_\_                 |
| > **Ref. VA Handbook 7176 Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 10. 2. 1002 b.**                |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. For secondary inventories?  |    |    | \_\_\_                 |
| > **Ref. VA Handbook 7176 Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 10. 2. 1002 b.**                |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. How often are levels        | \_ |    |                        |
| > reviewed? **Ref. VA Handbook    | \_ |    |                        |
| > 7176 Part 10. 2. 1002 e. (3).** | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > d\. How many items were out of  | \_ |    |                        |
| > stock in the last 30 days?      | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part    | \_ |    |                        |
| > 10. 2. 1002 e. (3).**           | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 5\. What is the temperature and   | \_ |    |                        |
| humidity in this area? **Ref. VA  | \_ |    |                        |
| Handbook 7176 Part 10. 3. 1003    | \_ |    |                        |
| f.**                              | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 6\. Primary & Secondary           | \_ |    |                        |
| Sterile/nonsterile storage areas. | \_ |    |                        |
| Are the distances from the        | \_ |    |                        |
| ceiling, floor, or outside wall   | \_ |    |                        |
| in accordance with regulations?   | \_ |    |                        |
| **Ref. VA Handbook 7176 Part 10.  | \_ |    |                        |
| 3. 1003 a.**                      | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 7\. What type of shelving is used |    |    | \_\_\_                 |
| in the primary and secondary:     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| **Ref. Department Of Veterans     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Affairs, Training Manual SPD      |    |    |                        |
| Level 1. Training : (TP 90-2)     |    |    | \_\_\_                 |
| Sterile Storage 6. a & b**        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| a\. Open (metro wire, etc.)?      |    |    |                        |
|                                   |    |    |                        |
| > b\. Closed?                     |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 8\. How often are the shelves     | \_ |    |                        |
| cleaned: **Ref. VA Handbook 7176  | \_ |    |                        |
| Part 10. 3. 1003 a.**             | \_ |    |                        |
|                                   | \_ |    |                        |
| a\. Primary?                      | \_ |    |                        |
|                                   | \_ |    |                        |
| > b\. Secondary?                  | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 9\. Visit at least 10 percent of  | #  | #  | ######                 |
| the secondaries:                  | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   | #  | #  |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Are they neat and clean?    | #  | #  | ######                 |
| > **Ref. VA Handbook 7176 Part    | ## | ## |                        |
| > 10. 3. 1003 a.**                | ## | ## | \_\_\_                 |
|                                   | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Are there any items that    | #  | #  | ######                 |
| > are out of stock? **Ref. VA     | ## | ## |                        |
| > Handbook 7176 Part 10 2. 1002   | ## | ## | ###### \_\_\_          |
| > b**                             | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Have inventory levels been  | #  | #  | ######                 |
| > checked? **Ref. VA Handbook     | ## | ## |                        |
| > 7176 Part 10. 2. 1002 e 1, 2,   | ## | ## | ###### \_\_\_          |
| > 3**                             | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > \(1\) How often are they        | #  |    |                        |
| > reviewed? **Ref. VA Handbook    | ## |    |                        |
| > 7176 Part 10. 2. 1002 e.**      | ## |    |                        |
|                                   | #  |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > \(2\) How are the levels set?   | #  |    |                        |
| > **Ref. VA Handbook 7176 Part    | ## |    |                        |
| > 10. 2. 1002 e. 1, 2, 3**        | ## |    |                        |
|                                   | #  |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > \(3\) Average usage? Based on   | #  |    |                        |
| > what (by highest usage during a | ## |    |                        |
| > set period)? **Ref. VA Handbook | ## |    |                        |
| > 7176 Part 10. 2. 1002 e. (3).** | #  |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > \(4\) What is the period        | #  |    |                        |
| > (weeks, months, years)? **Ref.  | ## |    |                        |
| > VA Handbook 7176 Part 10. 2.    | ## |    |                        |
| > 1002 e. (3).**                  | #  |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 10\. Talk with a user and a       | #  | #  | ######                 |
| supervisor from each secondary    | ## | ## |                        |
| visited:                          | ## | ## |                        |
|                                   | #  | #  |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Are they satisfied with the | #  | #  | ######                 |
| > service provided by SPD? If     | ## | ## |                        |
| > not, how can service be         | ## | ## | \_\_\_                 |
| > improved? **Ref. VA Handbook    | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
| > 7176 Part 1. 1. 101 a, b, c &   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 10. 1. 1001 a.**           |    |    |                        |
|                                   |    |    | ###### \_\_\_          |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Is the level of supply high | #  | #  | ######                 |
| > enough to meet their needs? If  | ## | ## |                        |
| > not, what item(s) are they      | ## | ## | \_\_\_                 |
| > having problems with? **Ref. VA | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 1. 101 c &   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 10. 2. 1002 e3 & g**       |    |    |                        |
|                                   |    |    | ###### \_\_\_          |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Does the quality of the     | #  | #  | ######                 |
| > med/surg devices meet the       | ## | ## |                        |
| > patients' needs? If not, list   | ## | ## | \_\_\_                 |
| > items. **Ref. VA Handbook 7176  | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
| > Part 10. 1. 1001 a,b**          |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | ###### \_\_\_          |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > d\. What consituted the use of  | \_ |    |                        |
| > items at the medical center?    | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part    | \_ |    |                        |
| > 10. 1. 1001 a,b**               | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   |    |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > e\. Have concerns been reported | #  | #  | ######                 |
| > to the supervisors?             | ## | ## |                        |
|                                   | ## | ## | \_\_\_                 |
|                                   | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    |                        |
|                                   |    |    | ###### \_\_\_          |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 11\. Is there a location system   | #  | #  | ######                 |
| for use by SPD staff and Clinical | ## | ## |                        |
| staff in SPD primary and          | ## | ## | ###### \_\_\_          |
| secondaries? **Ref. VA Handbook   | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
| 7176 Part 1. 5. 104 c.**          |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 12\. Does the locator list        | #  | #  | ######                 |
| include equipment, prep room,     | ## | ## |                        |
| case cart, sterile core area?     | ## | ## | ###### \_\_\_          |
| **Ref. VA Handbook 7176 Part 1.   | #  | #  | \_\_\_\_\_\_\_\_\_\_\_ |
| 5. 104 c,d**                      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+

+-----------------------------------+----+----+------------------------+
| ##### CASE CART                   |    |    |                        |
|                                   |    |    |                        |
| ######                            |    |    |                        |
+===================================+====+====+========================+
|                                   | ## | #  | ###### Comments        |
|                                   | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   |  Y | #  |                        |
|                                   | es | No |                        |
+-----------------------------------+----+----+------------------------+
| 1\. Is this area separated from   |    |    | \_\_\_                 |
| the rest of the clean/sterile     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| storage area? **Ref. VA Handbook  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 7176 Part 9. 1. 901 a.**          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 2\. What is the dress attire for  | \_ |    |                        |
| this area? **Ref. VA Handbook     | \_ |    |                        |
| 7176 Part 9. 1. 901 a.**          | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Is it different from other  |    |    | \_\_\_                 |
| > clean/sterile storage area?     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > **Ref. VA Handbook 7176 Part    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 9. 1. 901 a.**                  |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. Is it the same as the       |    |    | \_\_\_                 |
| > preparation area? **Ref. VA     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 9. 1. 901    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > a.**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 3\. Are the case carts closed?    |    |    | \_\_\_                 |
| **Ref. VA Handbook 7176 Part 9.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 2. 902 4b**                       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > a\. If no, how are the carts    | \_ |    |                        |
| > covered? **Ref. VA Hanbook 7176 | \_ |    |                        |
| > Part 9. 1. 901 c.**             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. If there are reusable       | \_ |    |                        |
| > covers, how are they cleaned    | \_ |    |                        |
| > and how often? **Ref. VA        | \_ |    |                        |
| > Handbook 7176 Part 6. 7. 607    | \_ |    |                        |
| > b.**                            | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 4\. What percent of items used on | \_ |    |                        |
| a case cart are placed in the     | \_ |    |                        |
| cart by the SPD staff? **Ref. VA  | \_ |    |                        |
| Handbook 7176 Part 9. 2. 902 4a** | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 5\. Is there a quality assurance  |    |    | \_\_\_                 |
| system in place to make sure the  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| case carts are 100 percent        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| complete and accurate? **Ref. VA  |    |    |                        |
| Handbook 7176 Part 13. 6. 1306 a. |    |    |                        |
| 5**                               |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 6\. How are case carts            | \_ |    |                        |
| transported to the operating room | \_ |    |                        |
| suite? Are they protected in a    | \_ |    |                        |
| way which will not increase the   | \_ |    |                        |
| bio-burden in the operating room? | \_ |    |                        |
| **Ref. VA Handbook 7176 Part 9.   | \_ |    |                        |
| 2. 902 4a**                       | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 7\. How are the case carts and    | \_ |    |                        |
| reusable item returned to SPD?    | \_ |    |                        |
| **Ref. VA handbook 7176 Part 9.   | \_ |    |                        |
| 2. 902 4a**                       | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 8\. Is the IFCAP/GIP Case Cart    |    |    | \_\_\_                 |
| Computer System in use? **Ref. VA |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Handbook 7176 Part 9. 2. 902 4 a, |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| b**                               |    |    |                        |
+-----------------------------------+----+----+------------------------+

+-----------------------------------+----+----+------------------------+
| ##### PREPARATION                 |    |    |                        |
|                                   |    |    |                        |
| ######                            |    |    |                        |
+===================================+====+====+========================+
|                                   | ## | #  | ###### Comments        |
|                                   | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   |  Y | #  |                        |
|                                   | es | No |                        |
+-----------------------------------+----+----+------------------------+
| [Sterilization                    |    |    |                        |
| Records]{.underline}:             |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 1\. Are records maintained for    |    |    | \_\_\_                 |
| three years for all sterilizers:  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| **Ref\'s. VA Handbook 7176 Part   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 7. 1. 701 & Part 8. 8. 808 (3)**  |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Printouts/Graphs? **Ref\'s. |    |    | \_\_\_                 |
| > VA Handbook 7176 Part 7. 1. 701 |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > & Part 8. 803 (3)**             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Is each cycle signed?       |    |    | \_\_\_                 |
| > **Ref. VA Handbook 7176 Part 8. |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > 8. 808 (2)**                    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Biological Reports (at      |    |    | \_\_\_                 |
| > least daily, each EtO load with |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > each implant? **Ref\'s. VA      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 13. 4. 1304  |    |    |                        |
| > a. & Part 8. 8. 808 e. (1)**    |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > d\. Are Bowie Dick Tests        |    |    | \_\_\_                 |
| > performed (for each Pre-Vac     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > sterilizer, each day and after  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > each repair or shutdown)?       |    |    |                        |
| > **Ref. VA Handbook 7176 Part 8. |    |    |                        |
| > 2. 802. a 2**                   |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > e\. Is there a content list for |    |    | \_\_\_                 |
| > each sterilizer cycle (steam,   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > gas, and plasma)? **Ref. VA     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Handbook 7176 Part 13. 1. 1301  |    |    |                        |
| > f.**                            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 2\. Are there sterilizers located |    |    |                        |
| in: **Ref. VA Handbook 7176 Part  |    |    |                        |
| 7. 1. 701**                       |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. SPD?                        |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Operating Room?             |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Dental?                     |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > d\. G.I. Lab?                   |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > e\. ENT Clinic?                 |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > f\. Respiratory Therapy Clinic? |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 3\. Check the records listed      | \_ |    |                        |
| under paragraph 1. above for each | \_ |    |                        |
| sterilizer (pick one date for     | \_ |    |                        |
| each of the last 3 years and      | \_ |    |                        |
| check all of the requirements).   | \_ |    |                        |
| **Ref. VA Handbook 7176 Part      | \_ |    |                        |
| 13. 1. 1301 d. 1-7.**             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| a\. If sterilizers are used       | \_ |    |                        |
| without a recording (printing)    | \_ |    |                        |
| device, there must be a register  | \_ |    |                        |
| that contains the following       | \_ |    |                        |
| information for each cycle:       | \_ |    |                        |
| **Ref\'s. VA Handbook 7176 Part   | \_ |    |                        |
| 8. 8. 808 a. (1) a-h.**           | \_ |    |                        |
|                                   | \_ |    |                        |
| > Date                            | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Items in Load                   | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Length of Cycle                 | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Sterilization Temperature       | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Control Number Assigned         | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Signature of Operator           | \_ |    |                        |
| >                                 | \_ |    |                        |
| > Appropriate Remarks             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. What is the dress attire    | \_ |    |                        |
| > for the preparation room?       | \_ |    |                        |
| > **Ref. VA Handbook 7176 Part    | \_ |    |                        |
| > 7. 1. 701 a.**                  | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 4\. How is the dress attire       | #  |    |                        |
| different from: **Ref\'s. VA      | ## |    |                        |
| Handbook 7176.**                  | ## |    |                        |
|                                   | #  |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Decontamination? **Part 3.  | \_ |    |                        |
| > 4. 304 1-8**                    | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. Clean/Sterile Storage?      | #  |    |                        |
| > **Part 3. 6. 306**              | ## |    |                        |
|                                   | ## |    |                        |
|                                   | #  |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > c\. Case Cart Area? **Part 9.   | #  |    |                        |
| > 2. 902 4c**                     | ## |    |                        |
|                                   | ## |    |                        |
|                                   | #  |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > d\. Operating Room? **Part 9.   | #  |    |                        |
| > 2. 902 4c**                     | ## |    |                        |
|                                   | ## |    |                        |
|                                   | #  |    |                        |
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|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 5\. When are long sleeves worn?   | \_ |    |                        |
| **Ref. VA Handbook 7176 Part      | \_ |    |                        |
| 7. 1. 701 a.**                    | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 6\. When are mustaches and facial | \_ |    |                        |
| hair covered? **Ref. VA Handbook  | \_ |    |                        |
| 7176 Part 7. 1. 701 b.**          | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 7\. What is the dress attire from | \_ |    |                        |
| someone visiting the preparation  | \_ |    |                        |
| area? **Ref. VA Handbook 7176     | \_ |    |                        |
| Part. 7. 1. 701 a, b**            | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 8\. What is the dress attire for  | \_ |    |                        |
| preparation staff going on break  | \_ |    |                        |
| from the prep area? **Ref. VA     | \_ |    |                        |
| Handbook 7176 Part 7. 1. 701 a.** | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 9\. Is the Preparation Section    |    |    | \_\_\_                 |
| separated from other SPD areas    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| such as clean sterile storage and |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| case cart? **Ref. VA Handbook     |    |    |                        |
| 7176 Part 3. 9. 309.**            |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 10\. Are the doors to the         |    |    | \_\_\_                 |
| preparation area kept closed?     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| **Ref. VA Handbook 7176 Part 3.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 10. 310 d.**                      |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 11\. Are Implants held in SPD for |    |    | \_\_\_                 |
| 48 hours after sterilization?     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| **Ref\'s. VA Handbook 7176 Part   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 7. 5. 705 k. & Part 8. 9. 809     |    |    |                        |
| d.**                              |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 12\. Is there a list of Implants? |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 13\. Review the Implant release   | \_ |    |                        |
| form. How many have been used in  | \_ |    |                        |
| the last 3 months? **Ref. VA      | \_ |    |                        |
| Handbook 7176 Part 7. 5. 705 k.** | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 14\. Are the items removed from   |    |    | \_\_\_                 |
| the EtO aerator before            |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| completion? **Ref. VA Handbook    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| 7176 Part 7. 3. 703 d. (3).**     |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 15\. When is the control number   | \_ |    |                        |
| assigned and placed on the        | \_ |    |                        |
| sterilized items (before or after | \_ |    |                        |
| sterilization? **Ref. VA Handbook | \_ |    |                        |
| 7176 Part 8. 10. 810**            | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 16\. How many items are returned  | \_ |    |                        |
| for sterilization due to          | \_ |    |                        |
| outdates?                         | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 17\. Are items returned for       |    |    | \_\_\_                 |
| sterilization sent to             |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| decontamination for reprocessing  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| directly from the storage areas?  |    |    |                        |
| **Ref. VA Handbook 7176 Part      |    |    |                        |
| 6. 1. 601 b.**                    |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 18\. Are there any                |    |    | \_\_\_                 |
| disposable/single use items being |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| resterilized? If yes, what are    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| they? **Ref. VA Handbook 7176     |    |    |                        |
| Part 3. 2. 302 b-g & Part 7. 1.** |    |    |                        |
|                                   |    |    |                        |
| **702**                           |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 19\. Are written instructions     |    |    | \_\_\_                 |
| from the manufacturer on file as  |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| to how the items are to be        |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| processed? **Ref. VA Handbook     |    |    |                        |
| 7176 Part 7. 2. 702**             |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 20 Are all items being            |    |    | \_\_\_                 |
| sequentially wrapped? **Ref. VA   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Handbook 7176 Part 7. 5. 705 d.** |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 21\. What is the primary wrapping | \_ |    |                        |
| materiel? **Ref. VA Handbook 7176 | \_ |    |                        |
| Part 7. 3. 703 e.**               | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 22\. If primary wrapping material | \_ |    |                        |
| is muslin, how long is it used    | \_ |    |                        |
| before being replaced? **Ref.     | \_ |    |                        |
| Department of Veterans            | \_ |    |                        |
| Affairs,Training Manual SPD       | \_ |    |                        |
| Level 1. Training: (TP 90-2)      | \_ |    |                        |
| Packaging 2. A (2).**             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 23\. Are instruments checked for  |    |    | \_\_\_                 |
| proper function and condition     |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| each time they are assembled to   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| be wrapped? **Ref. Department of  |    |    |                        |
| Veterans Affairs, Training Manual |    |    |                        |
| SPD Level 1. Training: (TP 90-2)  |    |    |                        |
| Surgical Instrumentation 6. b**   |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Scissors by cutting one     |    |    | \_\_\_                 |
| > layer of gauze? **Ref.          |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Department of Veterans Affairs, |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Training Manual SPD Level 1.    |    |    |                        |
| > Training: (TP 90-2) Surgical    |    |    |                        |
| > Instrumentation 6. e.**         |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. Needle holders to hold a    |    |    | \_\_\_                 |
| > suture? **Ref. Department of    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Veterans Affairs,Training       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > Manual SPD Level 1. Training:   |    |    |                        |
| > (TP 90-2) Surgical              |    |    |                        |
| > Instrumentation 6. c.**         |    |    |                        |
+-----------------------------------+----+----+------------------------+

+-----------------------------------+----+----+------------------------+
| ##### DECONTAMINATION             |    |    |                        |
|                                   |    |    |                        |
| ######                            |    |    |                        |
+===================================+====+====+========================+
|                                   | ## | #  | ###### Comments        |
|                                   | ## | ## |                        |
|                                   | ## | ## |                        |
|                                   |  Y | #  |                        |
|                                   | es | No |                        |
+-----------------------------------+----+----+------------------------+
| 1\. What items are provided and   |    |    |                        |
| worn for personal protective      |    |    |                        |
| equipment (PPE) in                |    |    |                        |
| decontamination**: Ref. VA        |    |    |                        |
| Handbook 7176 Part 6. 3. 603 a.** |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Impervious shoe covers (not |    |    | \_\_\_                 |
| > paper)?                         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Full Face shield or goggles |    |    | \_\_\_                 |
| > and surgical face mask?         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > c\. Impervious gowns?           |    |    | \_\_\_                 |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > d\. Decontamination gloves (not |    |    | \_\_\_                 |
| > exam or surgical)?              |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 2\. Does each pick-up area have a |    |    | \_\_\_                 |
| covered bin or tote box? **Ref.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| VA Handbook 7176 Part 6. 6. 606   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| a.**                              |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. Is the bin or tote box      |    |    | \_\_\_                 |
| > exchanged at each pick-up?      |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
|                                   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| > b\. Are these bins or tote      |    |    | \_\_\_                 |
| > boxes transported to SPD in a   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| > closed or covered cart?         |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------+----+----+------------------------+
| 3\. What is the dress attire for  | \_ |    |                        |
| the pick-up areas? **Ref. VA      | \_ |    |                        |
| Handbook 7176 Part 6. 6 606 b. 1, | \_ |    |                        |
| 2**                               | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 4\. How are items processed in    | \_ |    |                        |
| the decontamation area? **Ref. VA | \_ |    |                        |
| Handbook 7176 Part 6. 10. 610 a   | \_ |    |                        |
| -g & 11. 611 a - m.**             | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| 5\. What items are hand washed?   | \_ |    |                        |
| **Ref. VA Handbook 7176 Part 6.   | \_ |    |                        |
| 10. 610 a, b, & d**               | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
|                                   |    |    |                        |
+-----------------------------------+----+----+------------------------+
|                                   |    |    |                        |
+-----------------------------------+----+----+------------------------+
|                                   |    |    |                        |
+-----------------------------------+----+----+------------------------+
|                                   |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 6\. Are all items transported to  |    |    | \_\_\_                 |
| the SPD Decontamination area in a |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| closed container or in a closed   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| or covered cart? **Ref. VA        |    |    |                        |
| Handbook 7176 Part 6. 2. 602 a.** |    |    |                        |
+-----------------------------------+----+----+------------------------+
| > a\. What type of container?     | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
+-----------------------------------+----+----+------------------------+
| > b\. What type of cart?          | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| 7\. For those areas that perform  |    |    | \_\_\_                 |
| their own decontamination, is the |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| decontamination area separated    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| from all other areas of the       |    |    |                        |
| department? **Ref. VA Handbook    |    |    |                        |
| 7176 Part 6. 2. 602 a.**          |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 8\. Are there any items stored in |    |    | \_\_\_                 |
| the decontamination area? If yes, |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| when will it be removed? **Ref.   |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| VA Handbook 7176 Part 6. 3. 603   |    |    |                        |
| b.**                              |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 9\. What is the air pressure in   | \_ |    |                        |
| the decontamination area? **Ref.  | \_ |    |                        |
| VA Handbook 7176 Part 6. 2. 602   | \_ |    |                        |
| a.**                              | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > a\. How many air exchanges per  | \_ |    |                        |
| > hour? **Ref. VA Handbook 7176   | \_ |    |                        |
| > Part 6. 2. 602 a.**             | \_ |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| > b\. How many air exchanges are  | \_ |    |                        |
| > there in the Preparation per    | \_ |    |                        |
| > hours? **Ref. VA Handbook 7176  | \_ |    |                        |
| > Part 3. 10. 310 d.**            | \_ |    |                        |
|                                   | \_ |    |                        |
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+-----------------------------------+----+----+------------------------+
| 10\. Is there a shower provided   |    |    | \_\_\_                 |
| for the SPD decontamination       |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| staff? **Ref. VA Handbook 7176    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| Part 6. 3. 603 b.**               |    |    |                        |
+-----------------------------------+----+----+------------------------+
| 11\. Can the shower be accessed   |    |    | \_\_\_                 |
| by the staff without              |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| contaminating the environment?    |    |    | \_\_\_\_\_\_\_\_\_\_\_ |
| **Ref. VA Handbook 7176 Part 6.   |    |    |                        |
| 3. 603 b. & Part 3. 4 304 d.**    |    |    |                        |
+-----------------------------------+----+----+------------------------+