# * *Physical Demonstration Evaluation

Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_

SS# \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Observer:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Facility \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## [Hands-on Demonstration for Personal Safety Section]{.underline}

A. Demonstrate the following:

\_\_\_\_\_\_\_\_ 1. Strike block

\_\_\_\_\_\_\_\_ 2. Single wrist grab

\_\_\_\_\_\_\_\_ 3. Double wrist grab

\_\_\_\_\_\_\_\_ 4. Two hands grabbing one wrist

\_\_\_\_\_\_\_\_ 5. Wrist grab with startle reflex

\_\_\_\_\_\_\_\_ 6. Choke (front and rear)

\_\_\_\_\_\_\_\_ 7. Hair pull (front and rear)

\_\_\_\_\_\_\_\_ 8. Kick

B. Explain the Death Grip safety move \_\_\_\_\_\_\_\_

## [Hands-on Demonstration for Personal Contact Skills]{.underline}

The trainer adequately demonstrates the team concept \"triangle\"
approach through the following:

\_\_\_\_\_\_ A. Setting the code word.

\_\_\_\_\_\_ B. Avoids encroaching in the patient1s Personal space and
maintains the supportive stance.

\_\_\_\_\_\_ C. Prevents patient from encroaching in team members
personal space.

\_\_\_\_\_\_ D. Employs verbal skills to set limits on disruptive
behavior and avoids using threats. If team is not present the person
should suggest alternatives, rather than setting limits that cannot be
enforced.

\_\_\_\_\_\_ E. Utilizes supportive hands-on escort approach.

The trainer adequately demonstrates the \"Hang Technique\" skill
positions as follows :

A. Side \'weight\" position

\_\_\_\_\_\_\_\_ 1. Weight distribution

\_\_\_\_\_\_\_\_ 2. Knee- locks

\_\_\_\_\_\_\_\_ 3. Hand position (forearm/upper arm)

\_\_\_\_\_\_\_\_ 4. Balance control

\_\_\_\_\_\_\_\_ 5. Head position

B. Back \" steering committee \" position

\_\_\_\_\_\_\_\_ 1. Bear hug around patient elbows

\_\_\_\_\_\_\_\_ 2. Head Position (upper back/face to the side)

\_\_\_\_\_\_\_\_ 3. Hand position once side team members are in position
(above elbow)

\_\_\_\_\_\_\_\_ 4. Weight distribution

\_\_\_\_\_\_\_\_ 5. Balance control / Supportive stance

C. \"Hang position to Back position\" exchange \_\_\_\_\_\_\_

D. \"Back position to Hang position\" exchange \_\_\_\_\_\_\_

The trainer adequately demonstrates the \"Take-Down\" maneuver from the
following positions:

A. Side \"weight\" to \"control\" position

\_\_\_\_\_\_\_\_ 1. Hand position (shoulder / forearm)

\_\_\_\_\_\_\_\_ 2. Both team member face forward on their knees .

\_\_\_\_\_\_\_\_ 3. Leg placement ( thigh under armpit)

\_\_\_\_\_\_\_\_ 4. Support shift (hands to patient\'s shoulder

5\. Control Position

\_\_\_\_\_\_\_\_ Hand Position

\_\_\_\_\_\_\_\_ Leg placement

\_\_\_\_\_\_\_\_ Weight distribution

B. Back "steering committee" to "take-down" position

\_\_\_\_\_\_\_\_ 1. Hand position (above elbow)

\_\_\_\_\_\_\_\_ 2. Knee placement (chair position)

\_\_\_\_\_\_\_\_ 3. Knee "ramp" placement

\_\_\_\_\_\_\_\_ 4. Feet displacement (patient's feet pulled out slowly)

\_\_\_\_\_\_\_\_ 5. Control position (lie across legs)

C. Patient turn over in preparation for transport. \_\_\_\_\_\_\_\_

The trainer adequately demonstrates integration of the above skills in a
three person role-play. \_\_\_\_\_\_\_

**[Observer Comments:]{.underline}**