Hand Hygiene and PPE Competency Checklist for Home Care Caregivers

An editable Hand Hygiene and PPE (Donning and Doffing) Competency Checklist for non-medical home care agencies.

For supervisors and trainers who watch caregivers demonstrate each step and record the result in the employee file.

What's included (5 pages; editable Word .docx):

• Pages 1-4: caregiver and observer details; Part A hand hygiene with soap and water; Part B alcohol-based sanitizer; Part C disposable gloves; Part D putting on PPE (gown or apron, mask, eye protection, gloves); Part E taking off PPE; Part F knowledge questions asked out loud; Part G result and plan; signatures
• Step-by-step rows with Met boxes for each skill
• Page 5: Agency Instructions page (remove before use)

How to customize:

1. Open the Word file and use Home > Replace > Replace All to change [Agency Name] to your agency's name.
2. Replace [City] and [State] in the letterhead the same way; [Agency Name] also sits in the gray page header from page 2 on, so check it there.
3. Enter the scrub time you teach and fill any [State] spots and blank values with your agency's own choices.
4. Add your logo to the letterhead if you want one (there is no logo box), then delete the final Agency Instructions page before use.

Some lines cross-reference policy numbers from a companion Policy & Procedure Manual (sold separately); edit them to match your own policies.

An agency record of an observed skills check, not a certification or an official course.

Customizable template, not legal advice; check your state's requirements. Not a license to operate, not HIPAA software, and no medical claims. It is not a clinical protocol, it is not a certification, and it does not promise that you meet any law or standard; review it against current public health guidance and your state's rules before use.