Decontamination Competency Checklist Form
Evaluate and document an individual's competency in decontamination procedures. Please complete all sections accurately.
Trainee Full Name
*
First Name
Last Name
Date of Evaluation
*
-
Month
-
Day
Year
Date
Department/Unit
*
Evaluation Context
*
Please Select
Direct Observation
Simulation
Verbal Demonstration
Other
Competency Checklist
*
Rows
Not Demonstrated
Partially Demonstrated
Fully Demonstrated
Wears appropriate PPE
1
2
3
Prepares decontamination area
4
5
6
Follows correct decontamination steps
7
8
9
Handles contaminated materials safely
10
11
12
Disposes of waste correctly
13
14
15
Comments on Performance
Overall Competency Result
*
Competent
Needs Improvement
Not Competent
Assessor Full Name
*
First Name
Last Name
Assessor Role/Title
*
Assessor Signature
*
Submit Evaluation
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Should be Empty: