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477 <br />80 <br />Revised 01 -25 -05 <br />OBSERVATION CHECKLIST <br />Employee: <br />Dept./Div.: <br />Check <br />pertinent items. <br />1. <br />WALKING: <br />_Stumbling <br />_Staggering <br />_Failing _Unable to <br />_Swaying <br />Unsteady <br />Holding on <br />2. <br />STANDING: <br />_Swaying <br />_Rigid <br />_Unable to <br />_Feet wide apart <br />_Staggering <br />_Sagging at knees <br />3. <br />SPEECH: <br />_Shouting <br />_Silent <br />Whispering <br />_Slow <br />Rambling <br />Mute <br />_Slurred <br />Slobbering <br />Incoherent <br />4. <br />DEMEANOR: <br />_Cooperative <br />_Polite <br />_Calm <br />Sleepy <br />_Crying <br />_Silent <br />Talkative Excited <br />_Sarcastic <br />—Fighting <br />5. <br />ACTIONS: <br />Fighting <br />_Calm <br />_Drowsy <br />Hyperactive <br />_Hostile <br />Erratic <br />Profanity <br />Threatening <br />_Resisting communications <br />6. <br />EYES: <br />Watery <br />_Dilated <br />_Bloodshot <br />_Droopy <br />_Closed <br />_Glassy <br />7. <br />FACE: <br />Flushed <br />_Pale <br />_Sweaty <br />8. <br />CLOTHING: <br />_Unruly <br />_Messy <br />_Dirty <br />_Neat <br />(APPEARANCE) <br />_Partially dressed <br />_Having Odor <br />_Stains on clothing <br />Bodily excrement stains <br />9. <br />BREATH: <br />No Alcoholic odor <br />Alcoholic odor <br />10. <br />MOVEMENT: <br />_Fumbling <br />Jerky <br />_Slow <br />_Nervous <br />_Hyperactive <br />_Normal <br />11. <br />EATING/ <br />_Gum <br />_Candy <br />_Mints <br />CHEWING: <br />Other- identify if possible <br />12. <br />OTHER OBSERVATIONS: <br />Employee <br />Supervisor <br />Si nature: <br />Si nature: <br />Date/Time <br />Witness <br />Completed: <br />Signature: <br />80 <br />Revised 01 -25 -05 <br />