&
&
Skills
Verification
Sheet
Name:
Agency:
Date:
General XCollar Application
S
–
A
– X
Neutral
Position
Application
1.
SETUP
√
Extends
the
Side
Pieces;
Unfolds
and
Locks
the
Back
Piece.
2.
ADJUST
√
Encircles
the
patient
and
connects
the
Buckle,
while
maintaining
the
chin
secured
between
the
Chin
Strap
(front)
and
Padding
(below).
Adjusts
Side
Straps
to
patient
circumference
using
a
“push
&
pull”
(Opposing
Forces)
method.
Extends
the
anterior
Chest
Piece
to
upper
chest
without
distracting
the
c
‐
spine
and
locks
it
in
place.
3.
X
‐
STRAPS
Deploys
the
X
‐
Straps,
places
them
between
the
4
guides
maintaining
tension,
using
a
“push
&
pull”
(Opposing
Forces)
method.
√
Attaches
the
X
‐
Straps
to
the
matching
color
coded
Velcro.
Ensures
the
XCollar
is
securely
and
properly
applied.
In
Position
of
Comfort
&
Prone
Application
Properly
completes
the
S
‐
A
‐
X
points
of
General
XCollar
Application.
Tightens
Lateral
Side
Strap
on
the
side
the
patient
is
facing
first
and
the
other
Side
Strap
second.
√
Extends
and
locks
Adjustable
Chest
Support
asymmetrically
ensuring
padding
has
good
contact
on
upper
sternum.
Secures
X
‐
Strap
on
the
side
the
patient
is
facing
first
and
then
the
other
X
‐
Strap
second.
Supine
Position
Application
Properly
completes
the
S
‐
A
‐
X
points
of
General
XCollar
Application.
Slides
Back
Piece
at
a
45
degree
angle
to
midline
between
shoulder
blades.
Pushes
on
the
XCollar
and
pulls
on
clothing
to
properly
position
Back
Support.
√
Ensures
proper
placement
of
the
occipital
pad
without
patient
manipulation.
Airway
Management
Loosens
the
Chin
Strap
to
allow
proper
sealing
of
a
BVM
mask
using
“EC
clamp”
holding
technique
making
the
E
under
the
XCollar
Chin
Piece.
Demonstrates
the
steps
of
removal
in
reverse
application
order
to
allow
advanced
airway
insertion.
Head
Restraint
System
Application
√
Uses
the
correct
amount
of
padding
for
occipital
region
to
keep
patient
in
proper
in
‐
line
position.
Detaches
X
‐
Strap
and
attaches
Securing
Strap
on
the
Velcro
and
reattaches
the
X
‐
Strap
(repeat
on
opposite
side).
Attaches
Securing
Straps
to
the
carrying
device
without
pulling
tension.
Evaluator’s
Name:
√
By
signing
this
form,
the
“Evaluator”
is
verifying
that
the
Provider
named
at
the
top
of
this
page
has
successfully
demonstrated
all
manipulative
skills
required
by
this
training
course
and
this
Skills
Verification
Sheet
in
accordance
with
the
manufacturer
recommendations.
Emegear,
LLC
may
not
be
held
liable
for
any
hands
‐
on
skills
verification
since
they
are
not
being
verified
by
manufacturer
‐
approved
instructors.
Signature:
Date:
www.training.xcollar.com