Table 2.

APSIC central line insertion checklist

Name of patient				Age		Sex		Unique ID
Name of Insertor				Date		Time		Unit
Is the Indication for insertion appropriate?									Yes	No
Type of Central Venous Catheter	Tunneled		Non-Tunneled		PICC line		Chemoport		Any other:
Emergency Procedure	Yes	No
The Insertion Procedure
Was sublclavian or IJ vein the site for insertion - Y/N
Has insertor and assistant performed hand hygiene procedures, either by washing hands with liquid soap and water or with alcohol-based hand rubs (ABHR)?									Yes	No
Was 70 % alcohol and >0.5 % CHG used in cleaning site of insertion?									Yes	No
Have both the operator and assistant practised maximal sterile barrier precautions (wearing a sterile gown, sterile gloves, and cap and using a full body drape for patient)?									Yes	No
Signature of person in-charge: