Donning And Doffing PPE Competency Validation Checklist

• Site/Department

• Conducted on

  Date

• Person Conducting Assessment

  Employee

  Evaluator

• Prepared by

• Location
  Address

• LEVELS OF PERFORMANCE (L of P)
  0 Not Applicable
  1 Needs Assistance Little or No Experience
  2 Minimal Assistance Some Experience
  3 Perform Independent Competent/Experienced
  4 Resource/Instructor Competent/Able to Teach
  
  LEGEND
  A. Review Policy
  B. Direct Observation
  C. Video Review/Testing
  D. Skills Lab/Proficiency Testing
  E. Use of Learning Management System (LMS)
  F. Other (Specify)

• Are you the employee or evaluator?

  Evaluator

  Employee

Donning PPE with Donning Partner /Equipment

• Appropriately works with a donning partner

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Performs donning in a clean area

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Ties hair up and back from face

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Perform Hand Hygiene

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Applies Boot Covers

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Dons Surgical Cap/hair cover

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Dons Gown. Note: ALL TIES should be properly secured with a SIMPLE BOW. (Ensure all fit well and cover the intended areas. The head covers should be pulled over the ears during patient care for additional protection.)

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Apply N95 respirator. (Seal mask to the face ensuring straps are not crossed and properly located at the crown of the head and base of the neck.)

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Perform a fit check of the respirator

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Applies Face Shield

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Apply Standard Gloves

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Apply long cuff Nitrile gloves over the standard gloves

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Utilizes donning partner for assistance and to obtain any supplies.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Equipment: • Gown • Surgical Cap/Hair Cover • N-95 Respirator • Surgical Mask with Face Shield • Standard Gloves • Long Cuff Nitrile Gloves • Boot Covers • Trash Receptacles • Hand Sanitizers

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Uses chlorox bleach wipe to clean long cuff Nitrile Gloves Uses second chlorox wipe to open the door to the decontamination room

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Steps out of patient room into decontamination room with trash receptacle at door

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Removes the long cuff Nitrile Gloves using glove-inglove technique and discards in trash

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• Has doffing partner (who is wearing PPE and has not touched the patient) untie the gown

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Uses gentle, slow technique to remove the gown

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Maintains clean gown sleeves over gloved hands as much as possible and gather the gown, keeping dirty surfaces to the inside, rolling it up gently.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately discards in the trash.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately removes the inner standard patient care gloves using glove-in-glove technique.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Performs hand hygiene.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Applies new pair of gloves

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately removes the leg/boot covers one at a time. (Technique of rolling the dirty side in to eliminate contact with other objects around).

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately steps into Decontamination Room and discards covers in trash.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately removes the standard patient care gloves using glove-in-glove technique and discards in trash.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Utilizes Doffing Partner (who is wearing PPE and has not touched the patient) to assist removing N95

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately places N95 in trash.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately removes the surgical cap

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately places surgical cap in trash

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Performs Hand Hygiene

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Applies new pair of gloves

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Appropriately wipes shoes with bleach wipe and disposes of in trash

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Changes scrubs, shower if needed.

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

• Equipment: • Hand Sanitizers • Chlorox Bleach • Wipes • Extra Gloves • Trash Containers

  Select 0 1 2 3 4 N/A

  • 0
  • 1
  • 2
  • 3
  • 4
  • N/A

• How Met?

  Select A B C D E F

  • A
  • B
  • C
  • D
  • E
  • F

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