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

Observation

  • 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

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