Policies,Administrative,UWHC,UWHC-wide,Environmental Safety

Personal Protective Equipment (12.44)

Personal Protective Equipment (12.44) - Policies, Administrative, UWHC, UWHC-wide, Environmental Safety


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Administrative (Non-Clinical) Policy
 UWHC only (Hospital Administrative-entity wide)  UWMF only (entity wide)
 UWHC Departmental (indicate name)  UWMF Departmental (indicate name)
 UWHC and UWMF (shared)
Policy Title: Personal Protective Equipment
Policy Number: 12.44
Effective Date: July 1, 2015
Chapter: Environmental Safety
Version: Revision

A safe environment shall be provided for all UWHC employees. When engineering (such as increased
ventilation) or administrative policies and procedures will not provide an acceptable level of protection,
personal protective equipment will be provided to achieve safe working conditions. When personal
protective equipment (PPE) is necessary, the requirements of this policy shall be followed.


This policy establishes the minimum requirements for the use of personal protective equipment. PPE,
including but not limited to protective equipment for eyes, face, head and extremities, protective clothing,
respiratory devices, and protective shields and barriers, shall be provided, used and maintained in a
sanitary and reliable condition. The equipment shall be used wherever it is necessary by reason of hazards
of processes or environment, chemical hazards or mechanical irritants encountered in a manner capable of
causing injury or impairment in the function of any part of the body through absorption, inhalation or
physical contact.


Each employee's Supervisor is responsible for:
A. Ensuring that an assessment is conducted to determine if hazards are present, or are likely to be
present, which necessitate the use of personal protective equipment (PPE). Consideration should
be given to the basic hazard categories:

*Impact *Heat
*Penetration *Harmful dust
*Chemical *Light (optical) radiation
*Infectious Agents *Radiation

B. If such hazards are present, or likely to be present, the Supervisor shall conduct a hazard
assessment. The Director, Life Safety should be contacted if assistance is needed in conducting
the hazard assessment.

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C. Ensure that each affected employee have available and use the types of PPE that will protect the
individual from hazards identified in a hazard assessment.
Select PPE that properly fits each affected employee.
D. Ensure that all PPE be inspected, cleaned and maintained at regular intervals so that it provides
the requisite protection.


The Supervisor shall ensure that each employee who is required to use PPE be required to know at least
the following:
A. when PPE is necessary;
B. what PPE is necessary;
C. how to properly don (put on), doff (take off), adjust and wear PPE;
D. the limitations of the PPE; and
E. the proper care, maintenance, useful life and disposal of the PPE.

Each affected employee shall demonstrate an understanding of the above information to the satisfaction of
the supervisor before being allowed to perform work requiring the use of PPE. The Supervisor will
ensure the employee is retrained when changes to type of PPE occur or when the employee is not
demonstrating competence in use of the PPE. The employee is responsible for wearing the appropriate
PPE. The Supervisor shall document training.


WI Adm Code, Department of Commerce, Chapter COMM 32, Public Employee Safety & Health, Feb
1999.Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910.132; General PPE
OSHA Standard 29 CFR 1910.133; Eye and Face Protection
OSHA Standard 29 CFR 1910.134; Respiratory Protection
Policy 12.49 - Respiratory Protection Program
OSHA Standard 29 CFR 1910.135; Head Protection
OSHA Standard 29 CFR 1910.136; Foot Protection
OSHA Standard 29 CFR 1910.95; Occupational Noise
OSHA Standard 29 CFR 1910.1030; Bloodborne Pathogens
Hospital Administrative Policy 13.07-Standard Precautions & Transmission-based Precautions (Isolation)
for Inpatient Settings
Hospital Administrative Policy 13.28-Standard Precautions & Transmission-based Precautions (Isolation)
for Ambulatory Settings


Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Life Safety

Review/Approval Committee(s): Environment of Care Safety Committee; Administrative Policy and
Procedure Committee


Ronald Sliwinski
President & CEO

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Revision Detail:

Previous revision: 072012
Next revision: 072018