General Hospital • Operating Theatre

OT Visitor & Access Control Log

Mandatory Privacy & Safety Acknowledgement

By signing this log, the visitor acknowledges they have received permission to enter restricted OT zones and agrees to the following: 1) Privacy & Dignity: Absolute respect for patient privacy, modesty (Awrah), and confidentiality. 2) No Photography: Zero photography or video recording without explicit hospital/patient consent. 3) Supervision: Must remain with their designated host/surgeon and not touch sterile fields. 4) Attire: Full compliance with OT scrub attire, head covering, mask, and designated PPE requirements.

No. Visitor Name & Company/Institution Purpose of Visit Host / Supervisor Case / OR #
(if applicable)
Patient Consent
(Verified Y/N/NA)
PPE Checked
(✓)
Time In Visitor Signature
(Agrees to rules above)
Time Out
1
2
3
4
5
6
7
8
9
10
11
12
Reference: & Ethics Policy (SEC 4) Page 1 of 1