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<br />DRAFT <br /> <br />I OBSERV A TION CHECKLIST I <br />Employee: Dept./Div.: <br /> Check pertinent items. <br />1. WALKING: _Stumbling _Staggering _Failing Unable to <br /> _Swaying _Unsteady _Holding on <br />2. STANDING: _Swaying _Rigid Unable to <br /> _Feet wide apart _Staggering _Sagging at knees <br />3. SPEECH: _Shouting Silent - Whispering <br /> Slow _Rambling Mute <br /> Slurred _Slobbering Incoherent <br /> - - <br />4. DEMEANOR: _Cooperative Polite Calm <br /> - <br /> _Sleepy <br /> _Crying Silent Talkative Excited <br /> - - <br /> Sarcastic _Fighting <br /> - <br />S. ACTIONS: _Fighting Calm _Drowsy <br /> _Hyperactive Hostile Erratic <br /> - - <br /> _Profanity _Threatening _Resisting communications <br />6. EYES: Bloodshot _Watery Dilated <br /> - <br /> _Droopy Closed _Glassy <br />7. FACE: Flushed Pale _Sweaty <br /> - <br />8. CLOTHING: _Unruly _Messy _Dirty <br /> Neat <br /> - <br /> (APPEARAN CE) _Partially dressed _Having Odor _Stains on clothing <br /> _Bodily excrement stains <br />9. BREATH: No Alcoholic odor Alcoholic odor <br /> - - <br />10. MOVEMENT: _Fumbling _Jerky Slow <br /> - <br /> Nervous _Hyperactive Normal <br /> - <br />11. EATING! Gum _Candy Mints <br /> - <br /> CHEWING: _Other-identify if possible <br />12. OTHER OBSERV A TIONS: <br /> <br />Employee Supervisor <br />Sie:nature: Sie:nature: <br />r-, <br />Date/Time Witness <br />Completed: Sie:nature: <br /> <br />79 <br /> <br />Rev. 10/27/04 <br />