Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST

NAME: _____________________________________ DATE PERFORMED: _________________

YEAR & SECTION: ___________________________

DONNING AND DOFFING OF PPE (PERSONAL PROTECTIVE EQUIPMENT)

Definition: Personal protective equipment, commonly referred to as "PPE", is

specialized clothing or equipment worn for protection against infectious
material. (OSHA)
Goal: Improve personnel safety in the healthcare environment through appropriate
use of PPE.
Purpose: 1. Provide information on the selection and use of PPE.
2. Provide how to safely don and remove PPE

PREPARATION 1 2 3 4 5
Pre-donning instruction:
 Tie hair back
 Remove jewelry
 Check PPE for appropriateness of size
 Perform hand hygiene and make sure that hands
are dry
 Check all needed materials and arrange them
according to use

Assemble equipment:
 Socks
 First pair of Gloves
 Shoe cover
 Gown
 Scissors (for cutting/creating thumb hole)
 Rubber boots
 N95 respirator mask
 Medical or Surgical face mask
 Apron
 Second pair of Gloves
 Goggles
 Face shield

1. Check medical record and nursing plan of care for type

of precautions and review precautions in infection
control manual.
2. Plan nursing activities before entering patient’s room.
4. Provide instruction about precautions to patient, family
members, and visitors.

PUTTING ON PPE (COVER ALL / GOWN)

1. Healthcare workers should wear socks
2. Put on shoe cover on top of the socks
3. Put on first pair of gloves
4. Put on cover all / gown
5. Make thumbholes at border of cuff /
Sleeves, using the scissors
6. Put on rubber boots; make sure that pants leg covers the
boots
7. Wear on the N95 respirator mask by holding the mask
 on the cup of your hand with the ropes hanging. Place
the mask on face, then pull the top strap over the head
and place at the back of the head and the bottom strap at
the back of the neck just below the ear. Make sure that it
fit snug to face and chin.
8. Complete a user seal check
9. Put on surgical mask / medical mask
10.Put on hood / head cover, covering the cheeks and
forehead
11. Put on outer apron tie with simple bow
12. Put on outer gloves, covering the cuff of the sleeves
13. Put on face shield or goggles
14. Extend the arms upward and sideward and, bend at the
waist, to make sure that you are comfortable and to
ensure there is sufficient range of movement.
DOFFING / REMOVING OF PPE
STATION 1:
1. Step on the foot bath
2. Remove rubber boots
3. place in soaking solution

STATION 2: (REMEMBER TO DISINFECT EVERY

OTHER STEP)
1. Disinfect outer gloves
2. Remove outer gloves and dispose properly in
designated trash receptacle
3. Disinfect inner gloves
4. Remove apron. Remove tie and lift strap over the head
and roll apron from inside out and away from the body.
Dispose apron properly in designated trash receptacle
5. Disinfect inner gloves
6. Remove face shield / goggles, dispose in trash
receptacle
7. Disinfect inner gloves
8. Remove hood / head cover
9. Disinfect inner gloves
10. Remove surgical / medical mask; dispose in trash
receptacle
11. Disinfect inner gloves
12. Remove cover all / gown. Locate the zipper at the top
of the suit and pull it down completely. Grasp the outside
of the coverall from the back and pull it off from the both
arms in a downward motion. Roll coverall from inside to
outside and dispose properly.
13. Disinfect inner gloves
STATION 3:
1. Remove shoe cover
- Remove shoe cover one at a time, dispose
properly
- As you remove 1 shoe cover cross over the
clean area
- Do the same on your other foot
2. Disinfect inner gloves
3. Remove inner gloves, dispose properly
4. Disinfect hand
5. Proceed to shower room
STATION 4:
1. Do hand washing with soap and water
2. Remove N95 respirator
3. Put N95 inside paper bag
4. Do hand washing (soap and water)
5. Remove clothes & put inside the plastic bag
6. Do hand washing (soap and water)
7. Take a shower
8. Proceed to dressing room
9. Bring plastic bag w/ dirty clothes & paper
containing the n95
10. Disinfect hand
10. Put on new clothes then exit.

TOTAL:

________________________
Clinical Instructor
(Signature over printed name)