HR & employment 2 signers 2 pages 16 blanks to fill in

Infection Control Policy Acknowledgement

A signed record that each team member knows the hygiene routine, when to stay home, and exactly what to do after a needlestick.

Use this template — free See the agreement Signers don’t need an account
Infection control policy acknowledgement
The blanks in brackets are what you fill in. FileIt adds each signer’s signature and date boxes.
Infection control policy acknowledgement — page 1 of 2
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Infection control policy acknowledgement — page 2 of 2
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Use this template Fill in the blanks, name who signs, and send — from FileIt eSignature.

What is a infection control policy acknowledgement?

Infection control depends on everyone doing the same small things every time: clean hands, fresh gloves, a properly cleaned couch, sharps straight into the bin. When an inspector asks, or something goes wrong, you need to show that each person was told the rules and agreed to follow them.

This acknowledgement works for clinics, dental practices, salons, spas, tattoo studios and care services. You name the setting and the infection control lead, list the protective equipment and cleaning routine for the role, add instrument sterilising if staff reprocess equipment, say whether the role uses sharps, and set out when staff must stay away from work, following your public health authority's guidance. The employee agrees to hand hygiene, PPE use, cleaning and waste rules, reporting illness, and a four-step response to exposure incidents: wash, report, get same-day medical assessment, and record. Optional fields cover vaccination offers and the training date.

Best for
Clinics, dental practices, salons, spas, studios, care homes, home care
Signed by
The employee and a manager or infection control lead
Covers
Hand hygiene, PPE, cleaning, sterilising, sharps, waste, illness, exposures
Length
2 pages

When to use a infection control policy acknowledgement

  • A new nurse or dental assistant during induction
  • Salon and spa therapists who use blades, needles or wax
  • Care workers in a residential home or visiting clients at home
  • Re-acknowledgement after the policy is updated for new guidance
  • Evidence of staff training for an inspection or licensing visit

What you fill in

16 blanks, then the name and email of each person who signs: employee, employer.

1 Details

  • Business name*
  • Type of setting*
  • Employee's full name*
  • Job title
  • Policy title*
  • Policy dated
  • Infection control lead*

2 Equipment and cleaning

  • Protective equipment for the role*
  • Cleaning and disinfection routine*
  • Sterilising reusable instruments (optional)

3 Sharps and exposure

  • The role uses needles, blades or other sharps* Yes · No
  • Report exposure incidents to*
  • Where to get urgent medical assessment after an exposure*

4 Illness

  • When staff must stay away from work*
  • Vaccination (optional)
  • Infection control training completed on

5 Who signs

  • Employee signature and date
  • Employer signature and date, job title · The manager or infection control lead recording the acknowledgement.

What the infection control policy acknowledgement covers

  1. Hand hygiene
  2. Protective equipment
  3. Cleaning, disinfecting and sterilising
  4. Sharps and waste
  5. Illness and staying away from work
  6. Exposure incidents
  7. The Company's commitments

Using the infection control policy acknowledgement, step by step

1 Setting and lead

Your business name fills in from your account. Add the type of setting, the employee, job title, policy title and date, and the infection control lead.

2 PPE and cleaning

Edit the default protective equipment and cleaning routine to match the role, and add sterilising steps if staff reprocess instruments.

3 Sharps, exposure and illness

Say whether the role uses sharps, who receives exposure reports and where to get urgent medical assessment, and when staff must stay away from work.

4 Sign and file

Add any vaccination offer and the training date, then send. The employee signs and you countersign; the record is filed in your FileIt vault.

Tips before you send it

  • Take the stay-away rules from your public health authority's guidance for your type of setting.
  • Post the exposure steps and the medical contact on the wall next to the sharps bins.
  • Match the PPE list to each role rather than using one list for everyone.
  • Ask staff to re-sign whenever the policy is revised.

Sign it online in minutes

  1. Fill in the blanks. Names, dates and amounts go straight into the agreement — the preview shows exactly where.
  2. Name who signs. Tick “This is me” for your own part. FileIt builds the PDF with every signature, date box on the right line, and you can check or move anything before sending.
  3. Send it. Each signer gets a secure link and signs from any device — no account needed. The signed PDF, with an audit trail and a Certificate of Completion, is filed in your vault and emailed to everyone.
Use the infection control policy acknowledgement template — it’s free

Infection control policy acknowledgement: frequently asked questions

Does it suit a salon as well as a clinic?

Yes. You describe the setting, PPE and cleaning routine yourself, and the sterilising and sharps clauses only appear when they apply.

What does it say about needlestick injuries?

Wash the area with running water without scrubbing, report it immediately, get urgent medical assessment the same day at the place you name, and record it on the incident form.

Does it require vaccination?

No. You can record a vaccination the company offers, and the form says taking it up is the employee's choice unless the law or the role requires it.

Is health information kept private?

Yes. The form says information about the employee's health is kept confidential and shared only with those who need it to manage the risk.

Use this template — free