Title Page
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Conducted on
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Prepared by
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Location
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Name of person being audited
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Designation
- Wellness
- Culinary
- Admin
- Life Enrichment
- Maintenance
- Marketing
- Resident
- Visitor
- External Care Partner
- Housekeeping
Donning PPE
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Performed Hand Hygiene
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Fastened gown at neck and waist
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Applied mask appropriately
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Donned eye protection
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Applied gloves to cover cuffs of gown
Doffing PPE
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Used proper glove in glove technique for removal
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Performed Hand Hygiene
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Removed gown using appropriate rolling technique (took care to not have outside of gown touch clothing)
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Performed Hand Hygiene
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Removed face shield or goggles without touching face
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Remove mask
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Performed Hand Hygiene
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Don fresh mask and sanitized eye protection
Observation
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Took care to not touch unprotected areas of the body or clothing
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Did not adjust mask or clothing after donning PPE
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Performed hand hygiene completing vigorous rubbing and allowing time to dry or washed hand with warm soap and water for min 20 seconds
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Disposed of or sanitized reusable PPE items appropriately
