Free 53532.FH11 - Indiana

PUBLIC FIRE & LIFE SAFETY II PRACTICAL SKILLS EVALUATION CHECK LIST
State Form 53532 (3-08) DEPARTMENT OF HOMELAND SECURITY / DIVISION OF TRAINING

Reset Form

INSTRUCTIONS:

1. This form is intended to be used as a record of the students performance of each skill listed and its associated National Fire Protection Association (NFPA) objective. 2. This form will serve as the permanent record for the practical skills testing of Public Fire & Life Safety II and should be kept in the personnel records at the fire department. 3. This form should be used for the evaluation of the student; however, the evaluator should refer to the Indiana Firefighting Training System Practical Skills book and NFPA standards for additional guidance on the proper completion of the demonstrated skill. 4. Report any errors or problems to the Indiana Firefighting Training System Certification section at 1-800-666-7784. A skill may not be evaluated by the instructor who taught that skill.

REMINDER:

Name of student (last, first, middle) Name of fire department / agency Location of test

Drivers license number

Firefighter certification number County DHS course number

SKILL Administration Planning & Development Planning & Development Planning & Development Evaluation Education Education

OBJECTIVE NFPA 1035; 3-2.1; 3-3.2; 2000 Edition NFPA 1035; 3-3.1; 2000 Edition NFPA 1035; 3-3.2; 3-3.3; 3-3.4; 2000 Edition NFPA 1035; 3-3.5; 3-3.6; 2000 Edition NFPA 1035; 3-4.1; 3-4.2; 2000 Edition NFPA 1035; 3-4.3; 3-4.4; 2000 Edition NFPA 1035; 3-4.5; 3-4.6; 2000 Edition

DATE (month, day, year)

PASS / FAIL

SIGNATURE OF EVALUATOR

LEAD EVALUATOR CERTIFICATION OF SKILLS I hereby certify that the student identified on this form has successfully completed all of the practical skills listed above. Falsification of this information may result in disciplinary action against the instructor or evaluator by the Board of Firefighter Personnel Standards and Education.
Signature of lead evaluator Printed name of lead evaluator Certification number Date (month, day, year)