Personal Protective Equipment (PPE) Competency Validation

• Employee Name

• Job Title

• Date

  Date
• Location
  Address

Donning PPE

• 1. Perform Hand Hygiene

  Yes

  No

  N/A

• 2. Don Gown:<br>Fully covering torso from neck to knees, arms to end of wrists

  Yes

  No

  N/A

• 3. Tie/fasten in back of neck and waist

  Yes

  No

  N/A

• 4. Don Mask/Respirator:<br>Secure ties/elastic bands at middle of head & neck

  Yes

  No

  N/A

• 5. Fit flexible band to nose bridge

  Yes

  No

  N/A

• 6. Fit snug to face and below chin (Fit-check respirator if applicable)

  Yes

  No

  N/A

• 7. Don Goggles or Face Shield:<br>Place over face and eyes; adjust to fit

  Yes

  No

  N/A

• 8. Don Gloves:<br>Extend to cover wrist of gown

  Yes

  No

  N/A

Doffing PPE

• 9. Remove Gloves:<br>Grasp outside of glove with opposite gloved hand; peel off

  Yes

  No

  N/A

• 10. Hold removed glove in gloved hand

  Yes

  No

  N/A

• 11. Slide fingers of ungloved hand under remaining glove at wrist

  Yes

  No

  N/A

• 12. Peel glove off over first glove

  Yes

  No

  N/A

• 13. Discard gloves in waste container

  Yes

  No

  N/A

• 14. Remove Goggles or Face Shield:<br>Handle by head band or ear pieces

  Yes

  No

  N/A

• 15. Discard in designated receptacle if re-processed or in waste container

  Yes

  No

  N/A

• 16. Remove Gown:<br>Unfasten ties/fastener

  Yes

  No

  N/A

• 17. Pull away from neck and shoulders, touching inside of gown only

  Yes

  No

  N/A

• 18. Turn gown inside out

  Yes

  No

  N/A

• 19. Fold or roll into bundle and discard

  Yes

  No

  N/A

• 20. Remove Mask/Respirator (respirator removed after exit room/closed door):<br>Grasp bottom, then top ties or elastics and remove

  Yes

  No

  N/A

• 21. Discard in waste container

  Yes

  No

  N/A

• 22. Perform Hand Hygiene

  Yes

  No

  N/A

Standard Precautions & Transmission Based Precautions

• 23. Staff correctly identifies the appropriate PPE for the following scenarios:

• a. Standard Precautions (PPE to be worn based on anticipated level of exposure)*

  Yes

  No

  N/A

• b. Contact/Contact Enteric Precautions (gown & gloves)

  Yes

  No

  N/A

• c. Droplet Precautions (surgical mask)

  Yes

  No

  N/A

• d. Airborne Precautions (fit-tested respirator if applicable)

  Yes

  No

  N/A

• *NOTE: Examples include: mask for coughing/vomiting patient, goggles/face shield for irrigating draining wound, gown for dressing change if scrubs may touch patient, etc.

Completion

• Additional Comments or follow up actions

• Employee Signature

  Sign

• Validator Signature

  Sign