Don & Doff

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Don PPE

• Items, that interfere with effective hand hygiene (e.g. rings, watch, bracelet), removed

  Yes

  No

  N/A

• Excessive jewellery not removed<br>

  Yes

  No

  N/A

• Watch not removed<br>

  Yes

  No

  N/A

• Bracelet not removed<br>

  Yes

  No

  N/A

• Hand hygiene performed (Routine)

  Yes

  No

  N/A

• Moment 2 not done<br>

  Yes

  No

  N/A

• Disposable protective gown put on

  Yes

  No

  N/A

• Appropriate mask or respirator put on, e.g.: • Surgical mask • P2 mask

  Yes

  No

  N/A

• Protective eyewear put on

  Yes

  No

  N/A

• Gloves donned

  Yes

  No

  N/A

• PPE checked

  Yes

  No

  N/A

Doff PPE

• Gloves removed

  Yes

  No

  N/A

• Hand hygiene performed after removing gloves

  Yes

  No

  N/A

• Protective eyewear removed

  Yes

  No

  N/A

• Disposable protective gown removed

  Yes

  No

  N/A

• Appropriate mask or particulate mask ,e.g.: • Surgical mask; • P2/N95 mask, removed

  Yes

  No

  N/A

• Hand hygiene performed following removal of all PPE

  Yes

  No

  N/A

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