HEALTH CARE PROVIDER CONTROLS

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* 1. FULL NAME

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* 2. DATE

Date / Time

Date

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* 3. Arrange the following steps for hand washing in the correct sequence. Check off the number that corresponds to the correct step in the box provided

	1	2	3	4	5	6	7
Apply Soap	Apply Soap 1	Apply Soap 2	Apply Soap 3	Apply Soap 4	Apply Soap 5	Apply Soap 6	Apply Soap 7
Wash hands for 15 seconds	Wash hands for 15 seconds 1	Wash hands for 15 seconds 2	Wash hands for 15 seconds 3	Wash hands for 15 seconds 4	Wash hands for 15 seconds 5	Wash hands for 15 seconds 6	Wash hands for 15 seconds 7
Turn on tap	Turn on tap 1	Turn on tap 2	Turn on tap 3	Turn on tap 4	Turn on tap 5	Turn on tap 6	Turn on tap 7
Rinse with running water	Rinse with running water 1	Rinse with running water 2	Rinse with running water 3	Rinse with running water 4	Rinse with running water 5	Rinse with running water 6	Rinse with running water 7
Turn off tap with paper towel	Turn off tap with paper towel 1	Turn off tap with paper towel 2	Turn off tap with paper towel 3	Turn off tap with paper towel 4	Turn off tap with paper towel 5	Turn off tap with paper towel 6	Turn off tap with paper towel 7
Dry with paper towel	Dry with paper towel 1	Dry with paper towel 2	Dry with paper towel 3	Dry with paper towel 4	Dry with paper towel 5	Dry with paper towel 6	Dry with paper towel 7
Wet hands	Wet hands 1	Wet hands 2	Wet hands 3	Wet hands 4	Wet hands 5	Wet hands 6	Wet hands 7

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* 4. You are required to perform the following tasks. Select the appropriate type of PPE to use. If no PPE is required, select “no PPE.” Check the appropriate boxes

	Gloves	Gown	Facial protection	No PPE
Push a bed	Push a bed Gloves	Push a bed Gown	Push a bed Facial protection	Push a bed No PPE	Push a bed
Wipe up a urine spill on the floor with paper towels	Wipe up a urine spill on the floor with paper towels Gloves	Wipe up a urine spill on the floor with paper towels Gown	Wipe up a urine spill on the floor with paper towels Facial protection	Wipe up a urine spill on the floor with paper towels No PPE	Wipe up a urine spill on the floor with paper towels
Remove a client/patient/resident’s dentures from his/her mouth	Remove a client/patient/resident’s dentures from his/her mouth Gloves	Remove a client/patient/resident’s dentures from his/her mouth Gown	Remove a client/patient/resident’s dentures from his/her mouth Facial protection	Remove a client/patient/resident’s dentures from his/her mouth No PPE	Remove a client/patient/resident’s dentures from his/her mouth
Help a client/patient/resident to exercise his/her arm	Help a client/patient/resident to exercise his/her arm Gloves	Help a client/patient/resident to exercise his/her arm Gown	Help a client/patient/resident to exercise his/her arm Facial protection	Help a client/patient/resident to exercise his/her arm No PPE	Help a client/patient/resident to exercise his/her arm
Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath	Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath Gloves	Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath Gown	Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath Facial protection	Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath No PPE	Take the temperature of a client/patient/resident who has new fever, cough, shortness of breath

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* 5. You have just performed continence care for a disoriented, uncooperative client/patient/resident, who has a new fever, cough and shortness of breath. You need to remove your PPE. Arrange the correct order for taking off PPE. Write the number that corresponds to the step in the box provided

	1	2	3	4	5
Remove eye Protection	Remove eye Protection 1	Remove eye Protection 2	Remove eye Protection 3	Remove eye Protection 4	Remove eye Protection 5
Perform Hand Hygiene	Perform Hand Hygiene 1	Perform Hand Hygiene 2	Perform Hand Hygiene 3	Perform Hand Hygiene 4	Perform Hand Hygiene 5
Remove Gloves	Remove Gloves 1	Remove Gloves 2	Remove Gloves 3	Remove Gloves 4	Remove Gloves 5
Remove Gown	Remove Gown 1	Remove Gown 2	Remove Gown 3	Remove Gown 4	Remove Gown 5
Remove Mask	Remove Mask 1	Remove Mask 2	Remove Mask 3	Remove Mask 4	Remove Mask 5

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* 6. Which of the following scenarios show the Health Care Provider using proper Routine Practices? Select “true” if the Health Care Provider follows Routine Practices and “false” if he/she does not. Check off all that apply

	TRUE	FALSE
A Health Care Provider wears double gloves and sometimes triple gloves for better protection of his/her hands	A Health Care Provider wears double gloves and sometimes triple gloves for better protection of his/her hands TRUE	A Health Care Provider wears double gloves and sometimes triple gloves for better protection of his/her hands FALSE
A Health Care Provider wears a lab coat when providing care to protect his/her clothing from being soiled	A Health Care Provider wears a lab coat when providing care to protect his/her clothing from being soiled TRUE	A Health Care Provider wears a lab coat when providing care to protect his/her clothing from being soiled FALSE
A Health Care Provider stores a mask in his/her pocket so it can be used immediately	A Health Care Provider stores a mask in his/her pocket so it can be used immediately TRUE	A Health Care Provider stores a mask in his/her pocket so it can be used immediately FALSE
A Health Care Provider cleans his/her hands immediately after removing gloves	A Health Care Provider cleans his/her hands immediately after removing gloves TRUE	A Health Care Provider cleans his/her hands immediately after removing gloves FALSE
A Health Care Provider wears eye protection over his/her prescription glasses to protect himself/herself from potentially infectious droplets	A Health Care Provider wears eye protection over his/her prescription glasses to protect himself/herself from potentially infectious droplets TRUE	A Health Care Provider wears eye protection over his/her prescription glasses to protect himself/herself from potentially infectious droplets FALSE