PPE Checklist and Procedures

• Site/Client

• Date

  Date

• Prepared by

• Location
  Address

PPE Equipment and Supplies Checklist

• Bleach Wipes

  ✔

  ✖

  N/A

• Doffi ng Pad

  ✔

  ✖

  N/A

• Duct Tape

  ✔

  ✖

  N/A

• Gloves

  ✔

  ✖

  N/A

• Goggles

  ✔

  ✖

  N/A

• Hand Sanitizer

  ✔

  ✖

  N/A

• Long Cuff Nitrile Gloves

  ✔

  ✖

  N/A

• N95 Respirator or PAPR

  ✔

  ✖

  N/A

• Plastic Apron

  ✔

  ✖

  N/A

• Surgical Boot Covers or Boots

  ✔

  ✖

  N/A

• Trash Recepticle

  ✔

  ✖

  N/A

• Tyvek Suit

  ✔

  ✖

  N/A

Donning PPE Procedure

• Put on Tyvek Suit. Do not zip up. Make sure the suit is large enough for movement.

  ✔

  ✖

  N/A

• Utilize a hoodless suit or tuck hood into back of the suit.

  ✔

  ✖

  N/A

• Put on boots or shoe covers.

  ✔

  ✖

  N/A

• Tape around boots. Knees should be bent while taping to ensure range of movement is not compromised.

  ✔

  ✖

  N/A

• Create a pull tab of tape that connects the upper part of the boot.

  ✔

  ✖

  N/A

• Apply hand sanitizer to hands and clean.

  ✔

  ✖

  N/A

• Don inner layer of gloves. Bring cuffs of suit over each glove.

  ✔

  ✖

  N/A

• Don longer layer of gloves. Make sure this layer covers the Tyvek suit to prevent exposure.

  ✔

  ✖

  N/A

• Tape the glove to the suit sleeve similarly to how boots were secured, by bending at the elbow and utilizing a pull tab of tape.

  ✔

  ✖

  N/A

• Place N95 Respirator over face. Tighten mask by pushing down and in with two fingers across metal tab at the top of the mask. Th e best seal may take up to 5 minutes to be established.

  ✔

  ✖

  N/A

• Place goggles over N95 Respirator. Ensure goggles do not create open pocket on N95 Respirator.

  ✔

  ✖

  N/A

• Extend hood over head and look for areas that may need to be taped to ensure security.

  ✔

  ✖

  N/A

• Tape zipper of suit, utilizing pull tab at the top of the zipper.

  ✔

  ✖

  N/A

• If needed, tape the exterior of the hood to goggles or N95 Respirator.

  ✔

  ✖

  N/A

Doffing PPE Procedure

• Note: Doffi ng partner wears same PPE as doff er and pays attention to hand hygiene.

• Remove outer apron if necessary.

  ✔

  ✖

  N/A

• Remove third pair of gloves if needed.

  ✔

  ✖

  N/A

• Wipe off suit or additional fl uids with bleach before leaving patient room.

  ✔

  ✖

  N/A

• Buddy checks PPE for degradation.

  ✔

  ✖

  N/A

• Pull helmet off , making sure not to touch outside of suit to skin or hair.

  ✔

  ✖

  N/A

• Remove goggles and N95 Respirator.

  ✔

  ✖

  N/A

• Pull tabs and remove tape from zipper.

  ✔

  ✖

  N/A

• Unzip suit and remove shoulders from suit.

  ✔

  ✖

  N/A

• Remove arms from suit. You may need to pull tabs of tape from your wrists to free hands from gloves.

  ✔

  ✖

  N/A

• Remove legs from suit. Only use inner clean glove to touch inside of suit.

  ✔

  ✖

  N/A

• Step away from pile of contaminated materials.

  ✔

  ✖

  N/A

Completion

• Additional Notes

• Sign Off

  Sign