Healthcare PPE Attestation

HEALTHCARE PPE ATTESTATION

Patient Name:    Date of Birth:

Medical Record Number:    Encounter Date:

Facility / Unit:    Room / Location:

PPE ISSUED

The following personal protective equipment was provided to the patient or patient representative at the time of encounter. Check all that apply:

Surgical mask

N95 / Filtering facepiece respirator

Face shield / goggles

Isolation gown

Gloves

Shoe covers

Other:

PPE CONDITION & FIT

Condition of PPE issued:

New / unopened    Reprocessed / reused (per facility protocol)    Damaged / Defective

If damaged or defective, describe:

Respirator fit testing performed: Yes No    If yes, Fit Test Date:

TRAINING AND INSTRUCTIONS

The patient or patient representative acknowledges receipt of instruction regarding proper PPE use. Check items explained and demonstrated:

Donning procedures

Doffing procedures

Disposal and containment

Reuse/extended use procedures (if applicable)

Hand hygiene and infection prevention

ACKNOWLEDGMENT AND ATTESTATION

By signing below I certify that I received the PPE items indicated above and that staff provided instruction on their proper use. I understand that proper PPE use reduces, but does not eliminate, the risk of exposure to infectious agents.

I agree to follow facility PPE policies and procedures, to report any malfunction or concern regarding issued PPE to healthcare staff immediately, and to return or dispose of PPE as instructed. I understand that failure to comply with PPE instructions may affect my care or access to certain services.

I authorize the recording of this attestation and the inclusion of relevant PPE issuance and training details in my medical record for continuity of care and compliance documentation.

This attestation is valid until: unless superseded by subsequent documentation.

PRIVACY ACKNOWLEDGMENT

I acknowledge that information recorded on this form will be treated as part of my protected health information and maintained in accordance with applicable privacy and confidentiality policies. I understand who to contact at the facility regarding privacy questions and requests concerning my health information.

I acknowledge receipt of PPE-related instructions and understand my responsibilities regarding use and care of PPE. I acknowledge

ADDITIONAL COMMENTS

FACILITY REPRESENTATIVE (PRINT)

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