Assessment Checklist Personal Decontamination

Instructions: Assess compliance of personnel to the guide Personal decontamination.

Candidate (name): Click here to enter text. Assessment date: Click here to enter a date.

Assessor (name): Click here to enter text.Candidate to demonstrate or describe each step.Assessor may ask questions to assess understanding of actions.

Competent

NYC

A. Preparation – candidate describe actions prior to arrival at siteBriefed on task, authority, discuss visit with owner/manager, read documents, check resources

☐ ☐

B. Safety & communication – candidate describes actions on arrival at sitePark safely, notify supervisor of arrival, contact owner/manager

☐ ☐

C. Set up – candidate to demonstrate work area set up1. Identify & mark entry/exit line ☐ ☐2. Layout resources, positioning for accessibility ☐ ☐3. Add water to tubs & make up decontamination solution – candidate can describe ☐ ☐4. Prepare resources to go on site ☐ ☐

D. Put on PPE – candidate removes shoes & excess clothing, washes hands, puts on PPE in correct order & completes buddy check

☐ ☐

1. Overalls on ☐ ☐2. Boots on (overall legs outside boots) ☐ ☐3. Mask or respirator on & fit checked ☐ ☐4. Eye wear on & fit checked ☐ ☐5. Overall’s hood on & zipped up ☐ ☐6. Gloves on (1-2 pairs based on risk, tape impervious pair to sleeves) ☐ ☐7. Head protection on (if required) ☐ ☐

E. Enter & work on site – candidate describes actions to enter & work on siteCheck PPE fit, only take required resources, decontaminate boots, wear PPE correctly on site

☐ ☐

F. Remove gross contamination – candidate demonstrates or describes taskRemove gross contamination from boots & outer gloves

☐ ☐

G. Decontaminate/dispose of resources – candidate demonstrates or describes taskWaste in bags, decontaminate resources & gross contamination tub

☐ ☐

H. Remove PPE – candidate removes PPE then disposes or decontaminates1. Decontaminate footwear & step onto tarp ☐ ☐2. Outer gloves & spray inner gloves ☐ ☐3. Head protection (if used) ☐ ☐4. Overalls (inside out) ☐ ☐5. Footwear ☐ ☐6. Eye protection ☐ ☐7. Mask/respirator ☐ ☐8. Inner gloves ☐ ☐9. Check all waste disposed of, then wash hands & face ☐ ☐10. Get dressed ☐ ☐

I. Waste, site clean-up, communication – candidate demonstrates or describes tasks1. Secure waste – seal bag, disinfect, double bag, seal, disinfect (on clean side) ☐ ☐2. Empty footbath & decontaminate; decontaminate or dispose of tarp ☐ ☐3. Kit repacked – separate clean from decontaminated/wet & waste ☐ ☐4. Disinfect work area & vehicle ☐ ☐5. Contact owner/manager & supervisor ☐ ☐

J. After departure tasks – candidate describes tasks performed after leaving the siteWash/clean vehicle, copy & complete records, waste disposal, restock, shower, laundry, susceptible sp. contact

☐ ☐

Record: Assessor to keep checklist for evidence of competency & provide copy to candidate to load in EMtrain.

Result: Competent ☐ Not Yet Competent (NYC) ☐Comment Click here to enter text.

Assessment checklist – Personal decontamination v4 (INT10/23871) 6 September 2018 Page 1 of 1