PPE Competency Checklist

Personal Protective Equipment (PPE) Competency Checklist*
- Identifies the proper PPE to gather and verbalizes that all appropriate PPE is available at point of use.
- Verbalizes proper steps in examining PPE for defects?
(PPE should ideally be put on outside of the home prior to entry. If unable to put on all PPE outside of the home, it is preferred that face protection (i.e., respirator and eye protection) be put on before entering home.) Demonstrates the ability to follow the proper sequence for donning PPE in the order below:
PPE Order – On*
- 1. Hand hygiene using hand sanitizer for 20 seconds cleansing all parts of hands, fingers and nail beds.
- 2. Dons gown: fully covering torso from neck to knees, arms, ends of wrists. Wrap around back. Tie/fasten in back of neck and waist.
- 3. Dons N95 respirator while ensuring air-tight fit.
- 4. Performs seal check.
- 5. Dons Face shield: Place over face and eyes, adjust to fit as needed.
- 6. Dons gloves covering wrist of gown.
- 7. Enters the patient home.
(PPE should ideally be removed outside of the home and discarded after visit. If unable to remove all PPE outside of the home, it is preferred that face protection (i.e., respirator and eye protection) be removed only after exiting the home.) Demonstrates the ability to follow the proper sequence for doffing PPE in the order belowr:
PPE Order – Off*
- 1. Exits patient home.
- 2. Doffs gloves: Grasp outside of glove with opposite gloved hand, peel off using glove in glove technique. Discards in appropriate waste container.
- 3. Doffs gown: Untie lower ties first and upper last without contamination using arm cross method. Pull away from neck and shoulders, touching inside of gown. Folds or rolls into bundle and discards in appropriate waste container.
- 4. Doffs mask/face shield: Grasp bottom, untie lower ties first and upper last, pulling up and away from head. Avoid touching front of mask/respirator. Discards in appropriate waste container or stores mask for reuse per policy
- 5. Discards all PPE by placing in external trash can before departing location. PPE should not be taken from the home in staff vehicle.
- 6. Performs hand hygiene using hand sanitizer
Employee Attestation of COVID-19 Vaccination Status*
- I have not received any COVID-19 vaccine.
- I am scheduled to receive the first dose.
- I do not plan to receive the vaccine.
- I have received one COVID-19 Vaccine, and a second dose is scheduled.
- I have received all COVID-19 Vaccine injections as required per manufacture. I understand I am considered fully vaccinated two weeks after the last dose.
- I have received a booster dose for COVID-19 as recommended.
- I have lost or am otherwise unable to produce required proof of COVID-19 vaccination.
The Agency is committed to providing all our employees with the safest possible workplace. As part of the COVID-19 Plan, we need to record who has or has not received a vaccine for COVID-19. Please check the box(s) that describes your COVID-19 Vaccination status:
Agency Policies and Checklists: By signing my name below, I acknowledge that I have read, understand, and will comply with all applicable agency policies, guidelines, and checklists.

By my signature below, I certify that this statement about my vaccination status is true and accurate. I understand that knowingly providing false information regarding my vaccination status on this form may subject me to criminal penalties.
Name*
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Signature*
Email*
Date*
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