Gait Belt Application Training Checklist Form
Document and verify staff training on proper gait belt application using this checklist form.
Staff Member Name
*
First Name
Last Name
Trainer Name
*
First Name
Last Name
Date of Training
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gait Belt Application Training Steps (Check all completed)
*
Explained purpose and use of gait belt
Selected appropriate gait belt size and type
Demonstrated correct placement around waist
Secured belt snugly but comfortably
Checked for proper fit (not too tight or loose)
Demonstrated safe ambulation with support
Demonstrated safe removal of gait belt
Answered questions regarding application and safety
Additional Comments or Observations
Submit Checklist
Should be Empty: