Form ADSD-003 "Protective Action Response Medical Status" - Florida

What Is Form ADSD-003?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 11, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADSD-003 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Form ADSD-003 "Protective Action Response Medical Status" - Florida

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ADSD-003
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Protective Action Response Medical Status
State-Operated Facility Staff / Law Enforcement Operated Facility Staff /
Contracted Detention Facility Staff
Date Completed: _____/_____/_____
____________________________________
_______________________________________
Title of Office or P.A.
Patient’s Name (Please print)
____________________________________
_______________________________________
Professional Address
Date of Examination
____________________________________
_______________________________________
Physician’s Name (Please print)
____________________________________
_______________________________________
Physician’s Signature
_______________________________________
License Number
_______________________________________
Licensing State
The patient identified above is unable to perform one or more of the Protective Action Response (PAR)
techniques required for the job.
(1) I have reviewed the description and/or video of the PAR techniques that was provided to me.
q The date by which I anticipate this patient to be able to perform the PAR techniques I have
checked is _____/_____/_____.
month
day
year
q This patient is permanently unable to perform the PAR techniques I have checked.
q Yes
q No
(2) This patient will remain under my continued care.
q If “Yes,” the next scheduled appointment with this patient is _____/_____/_____.
month
day
year
q If “Yes,” no appointment is scheduled.
___________________________________________________
Attachments: Description of each technique and/or PAR video
Medical Status / State-Operated/Law Enforcement Operated/Contracted Detention Facility Staff
Page 1 of 3
Revised 12/11/2006
ADSD-003
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Protective Action Response Medical Status
State-Operated Facility Staff / Law Enforcement Operated Facility Staff /
Contracted Detention Facility Staff
Date Completed: _____/_____/_____
____________________________________
_______________________________________
Title of Office or P.A.
Patient’s Name (Please print)
____________________________________
_______________________________________
Professional Address
Date of Examination
____________________________________
_______________________________________
Physician’s Name (Please print)
____________________________________
_______________________________________
Physician’s Signature
_______________________________________
License Number
_______________________________________
Licensing State
The patient identified above is unable to perform one or more of the Protective Action Response (PAR)
techniques required for the job.
(1) I have reviewed the description and/or video of the PAR techniques that was provided to me.
q The date by which I anticipate this patient to be able to perform the PAR techniques I have
checked is _____/_____/_____.
month
day
year
q This patient is permanently unable to perform the PAR techniques I have checked.
q Yes
q No
(2) This patient will remain under my continued care.
q If “Yes,” the next scheduled appointment with this patient is _____/_____/_____.
month
day
year
q If “Yes,” no appointment is scheduled.
___________________________________________________
Attachments: Description of each technique and/or PAR video
Medical Status / State-Operated/Law Enforcement Operated/Contracted Detention Facility Staff
Page 1 of 3
Revised 12/11/2006
(3) As you read the description or view the video of the techniques, check those that the patient is restricted from
performing. If the patient is restricted from performing all of the techniques, check “All Techniques.” An
explanation of why the patient is unable to perform the techniques must be provided.
REASON FOR EXEMPTION
TECHNIQUES
q
All Techniques
Countermoves
q
High Block
q
Mid-Range Block – Straight Arm Blows
q
Mid-Range Block – Roundhouse Blows
q
Low Block – “X” Block
q
Low Block – Leg Raise
q
Evasive Sidestep
q
Evasive Sidestep with Redirection
q
One Wrist / Forearm Grab Release
q
Two Wrist / Forearm Grab Release
q
Rear Two Hand Release
q
Two Hands Together Grab Release
q
Front Choke Backstroke Release
q
Front Choke Wrist Release
q
Rear Bear Hug Release
q
Front Bear Hug Release
q
Bite Escape
q
Headlock Escape
q
Full Nelson Escape
q
Double Arm Lock Escape
q
Front Hairpull Escape
q
Rear Hairpull Escape
q
Ground Defense
Medical Status / State-Operated/Law Enforcement Operated/Contracted Detention Facility Staff
Page 2 of 3
Revised 12/11/2006
TECHNIQUES
REASON FOR EXEMPTION
Touch Techniques
q
Straight Arm Escort - Extended
q
Straight Arm Escort - Close
Control Techniques
q
Ground Control
q
Baskethold
q
Wrap-Around
q
Arm Bar
q
Arm Control
q
Team Arm Control
Takedowns
q
Straight Arm to a Takedown
q
Baskethold to a Takedown
q
Arm Bar to a Takedown
q
Immediate Team Takedown
Mechanical Restraints
q
Standing Front Handcuffing/Uncuffing
q
Standing Rear Handcuffing/Uncuffing
q
Prone Handcuffing
q
Leg Cuffing/Uncuffing – Kneeling Position
q
Leg Cuffing/Uncuffing – Hands on Wall
q
Restraint Belt Application/Removal
q
Waist Chain Application/Removal
Searching
q
Person Search
Medical Status / State-Operated/Law Enforcement Operated/Contracted Detention Facility Staff
Page 3 of 3
Revised 12/11/2006
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