Donning ppe (either N95 Respirator Mask or papr unit) Operator’s name



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Donning PPE (either N95 Respirator Mask or PAPR Unit)



Operator’s name: (print) __________________________

Monitor’s name: (print) __________________________

Date:_____________Time:_____________am / pm

  • A new checklist must be completed for each healthcare worker entering the patient’s room.

  • The Monitor must read each step out loud before the actions are carried out.

  • Complete this checklist to confirm the integrity of the PPE.

  • The Monitor does not need to wear PPE for donning assistance.








N95 Respirator Mask




Check







PAPR Unit



Check

1

Fill in name, date and time on this form and sign in on the Log Sheet.




1

Fill in name, date and time on this form and sign in on the Log Sheet.




2




2

  • Remove extra attire such as sweaters, fleece and lab coats.

  • Secure glasses with a tie or retainer strap.

  • Tie long hair up so it is off collar and pin back hair with bobby pins, if necessary.




3

Perform hand hygiene.




3

Perform hand hygiene.




4

Put the blue gown on over your head and tie waist straps.





4

Put the blue gown on over your head and tie the waist straps.




5

Put on the appropriate size N95 respirator mask that you have been fit tested for.
If you failed fit-testing or have recently grown a beard, wear a PAPR instead





5

PAPR assembly - Operator should check that:

  • The clear plastic film is removed from both sides of the face shield.

  • Test the unit by depressing the black switch on top of the fan unit. A short beep should sound and the red light next to the switch should remain on.

  • Attach 2 round filters onto the sides of the unit.

  • Ensure the pull tabs have been removed from the middle of the flat surface of the filters.

  • The hose should be screwed into the unit and the back of the head cover.




6

Put face shield on over N95 mask




6

Place PAPR belt around waist and tighten belt.

Turn unit on and place head cover over head.




7

Put on a pair of Nitrile Gloves – pull glove cuffs over gown sleeves (white area of gown cuff should not be visible)




7

Put on a pair of Nitrile gloves – pull glove cuffs over gown sleeves (white area of gown cuff should not be visible)




8

Monitor: Verify that all PPE is on appropriately.





8

Monitor: Verify that all PPE is on appropriately.






This form must be returned to Infection Control. Please keep in the MERS binder until forms are collected. Updated 8/9/2016


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