DATE

HANDS-ON EVALUATION
For use of this form, see STP 11-25S14-SM-TG; the proponent agency is TRADOC.
TASK TITLE TASK NUMBER

SCORE
(Check One)
ITEM PERFORMANCE STEP TITLE
PASS FAIL
a b c d

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

P F

EVALUATOR'S NAME UNIT

SOLDIER'S NAME STATUS

GO NO GO
DA FORM 5164-R, SEP 1985 EDITION OF DEC 82 IS OBSOLETE APD LC v2.01