Title Page

  • Conducted on

  • Prepared by

  • Location

  • Name of person being audited

  • Designation

Donning PPE

  • Performed Hand Hygiene

  • Fastened gown at neck and waist

  • Applied mask appropriately

  • Donned eye protection

  • Applied gloves to cover cuffs of gown

Doffing PPE

  • Used proper glove in glove technique for removal

  • Performed Hand Hygiene

  • Removed gown using appropriate rolling technique (took care to not have outside of gown touch clothing)

  • Performed Hand Hygiene

  • Removed face shield or goggles without touching face

  • Remove mask

  • Performed Hand Hygiene

  • Don fresh mask and sanitized eye protection


  • Took care to not touch unprotected areas of the body or clothing

  • Did not adjust mask or clothing after donning PPE

  • Performed hand hygiene completing vigorous rubbing and allowing time to dry or washed hand with warm soap and water for min 20 seconds

  • Disposed of or sanitized reusable PPE items appropriately

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.