Table 2.

Hand hygiene questionnaire

Job Function:		□ Staff nurse	□ Consultant	□ Resident	□ Physiotherapist
Date: / /
1)	Is there a Hand Hygiene Protocol in the ICU or hospital that you are aware of?
	□ yes	□ no	□ don’t know
2)	If there is a protocol, what do you estimate your compliance rate at? ________
	□ never	□ 1-10%	□ 11-40%	□ 41-70%	□ 71-100%
3)	When you don’t disinfect your hands (use soap or an alcohol hand-rub to kill microbes) when you should, what is the reason why? (Please check all that apply)
	□ too busy	□ forget	□ unsure of need	□ out of product(s)
	□ product(s) not in convenient location		□ other____________
4)	To what degree do you think there is a relationship between good hand hygiene practices and preventing hospital acquired infections?
	□ Very weak	□ Weak	□ Neither weak nor strong	□ Strong	□ Very Strong
5)	When working with another caregiver and you forget to disinfect your hands before touching a patient, what percent of the time does your colleague remind you?
	□ never	□ 1-10%	□ 11-40%	□ 41-70%	□ 71-100%
6)	When working with a colleague who forgets to disinfect his/her hands before touching a patient, what percent of the time do you remind them?
	□ never	□ 1-10%	□ 11-40%	□ 41-70%	□ 71-100%
7)	How often (%) do you use these products to disinfect your hands –should add up to 100%.
	_____% soap and water alone	_____% alcohol gel or foam alone	_____% both	_____% neither
8)	Please rate your satisfaction with the hand hygiene practices (including glove practices) currently used at your hospital.
	□ dissatisfied	□ somewhat dissatisfied	□ neutral	□ somewhat satisfied	□ satisfied
10)	Please rate your satisfaction with hand hygiene materials currently used at your hospital.
	□ dissatisfied	□ somewhat dissatisfied	□ neutral	□ somewhat satisfied	□ satisfied
11)	If we could do one thing to help you with practicing appropriate hand hygiene, what would it be?