Trained Observer Checklist – Donning PPE

Date: ______Time: ______

Trained Observer: ______Healthcare Worker: ______

Donning PPE Instructions / Completed appropriately (Trained observer initials) / Comments
Healthcare worker hydrates and empties bladder prior to donning PPE
Healthcare worker changes into surgical scrubs
Healthcare worker changes into dedicated washable footwear
No personal items on healthcare worker
  • Jewelry
  • Watches
  • Cell phones
  • Pagers
  • pens

PPE ensemble below inspected by trained observer and in serviceable conditions
  • Gloves (inner)
  • Extended cuff gloves (outer)
  • boot covers
  • coverall
  • N-95 mask
  • Surgical hood
  • Face shield

Donning sequence read to the healthcare worker in a step-by-step fashion prior to donning the PPE ensemble
Healthcare worker performs hand hygiene with Antibacterial Hand Foam AND foam is allowed to dry before moving to next step
Healthcare worker puts on first pair of gloves
Healthcare worker puts on boot covers on a clean chair
Healthcare worker puts on gown and ties securely
Trained observer ensures that the cuff of the inner gloves are tucked under the sleeve of the gown
Healthcare worker has been fit tested per policy (reference the fit testing list for date and size on the hospital intranet) / Healthcare worker fit test date: ______
Healthcare worker N95 size: ______
Healthcare worker puts on the appropriate size N95 respirator
Healthcare worker performs a user seal check
Healthcare worker places a surgical hood over the N95 respirator
Trained observer ensures the surgical hood covers all areas below:
  • Hair covered
  • Ears covered
  • Neck covered
  • Extends past the neck to the shoulders

Healthcare worker puts on second pair of gloves with extended cuffs
Trained observer ensures the cuffs are pulled over the sleeves of the gown
Trained observer ensures the integrity of the ensemble
  • No cuts
  • No tears

Puts on face shield or eye protection
Healthcare worker performs movements below and trained observer ensures there is sufficient range of movement while all areas of the body remain covered
  • Extend arms
  • Raise arms above head
  • Bend at the waist
  • Squat

Healthcare worker disinfects outer-gloved hands with antibacterial hand foam AND allowed to dry
Trained observer and healthcare worker confirm that all necessary supplies are available in patient room prior to entering
Trained observer clears healthcare worker to enter room

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