Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location


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

  • Excessive jewellery not removed<br>

  • Watch not removed<br>

  • Bracelet not removed<br>

  • Hand hygiene performed (Routine)

  • Moment 2 not done<br>

  • Disposable protective gown put on

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

  • Protective eyewear put on

  • Gloves donned

  • PPE checked

Doff PPE

  • Gloves removed

  • Hand hygiene performed after removing gloves

  • Protective eyewear removed

  • Disposable protective gown removed

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

  • Hand hygiene performed following removal of all PPE

  • Sheet1

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.