Kingdom of Saudi Arabia                                                                                                                   المملكة العربية السعودية
Ministry of health
                                                                                                                                                           وزارة الصحة
             General directorate for
            infection prevention and                                                                                                                 اإلدارة العامة لمكافحة عدوى
                     control                                                                                                                             المنشئات الصحية
           Hospital : ------------------------------------------------- Directorate :---------------------------------------------Date :--------------------------
                                                                      Monitoring LOG FORM
                                                          Sterilization Monitoring Schedule
 Month:
           Day                DATE               Warm up                                   Bowie- dick test                                          Leak test                          Biological Test
                                                    Daily                                              Daily                                          Weekly                                             Weekly
                                          DONE
                                                 Failed
                                                           NOT DONE
                                                                       SIGNATURE
                                                                                   DONE
                                                                                          Passed
                                                                                                   Failed
                                                                                                            NOT DONE
                                                                                                                         SIGNATURE
                                                                                                                                     DONE
                                                                                                                                            Passed
                                                                                                                                                       Failed
                                                                                                                                                                NOT DONE
                                                                                                                                                                           SIGNATURE
                                                                                                                                                                                       DONE
                                                                                                                                                                                              NEGATIVE
                                                                                                                                                                                                         POSIYIVE
                                                                                                                                                                                                                    NOT DONE
                                                                                                                                                                                                                               SIGNATURE
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
REMARKS:
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CHIEF OF CSSD NAME:                                                                                                    SIGNATURE:
ST-15, 9.5 Monitoring Test Schedule (5)