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OHIO DEPARTMENT OF PUBLIC SAFETYDIVISION OF EMERGENCY MEDICAL SERVICES211974535098200LIVE FIRE TRAINING – OPERATIONS LEVEL PRACTICAL SKILLS EVALUATION PACKETCANDIDATE NAME (Please Print) FORMTEXT ?????CHARTER FORMTEXT ?????CHARTER # FORMTEXT ?????September 25, 2015All Live Fire Training Operations Course participants are required to complete Job Performance Requirements (JPRs) under the auspices of a chartered fire training program, within twelve months of completion of the 24-hour (minimum) course.The purpose of enclosed skills evaluation forms is for the evaluators to use them as a tool to give the live fire instructor candidate instructions and directives for each teaching point scenario, as well as to document evaluation of the required performance steps. Candidates are only required to be evaluated on the skills that are being performed for each JPR position.Once completed, these forms shall be placed in the charter course / student files along with the JPR check-off sheets.NOTE: A RATIO OF ONE INSTRUCTOR TO FIVE STUDENTS MUST BE MAINTAINED THROUGHOUT ALL PRACTICAL EVOLUTIONS.Refer to program director bulletin PD2015-07 Live Fire Training Instructor Requirements dated May 13, 2015, as a guideline.OHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTORCHARTER FORMTEXT ?????CHARTER # FORMTEXT ?????LEAD EVALUATOR FORMTEXT ?????CERT # FORMTEXT ?????OPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Ground Level Attack)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.001Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew before, during, and after ground level attack live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA** 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class. * International Fire Service Training Association** National Fire Protection AssociationPERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate personal protective equipment (PPE), confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including self-contained breathing apparatus (SCBA) FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate personal alert safety system (PASS) device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prior to entry, bleed air from hose line, check nozzle pattern and pressure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up building / fire conditions, fire location, wind direction, and environment for hazards FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish burning fascia, boxed cornices, or other doorway overhangs as necessary before entering FORMCHECKBOX Ensure that fire is not overhead or behind attack hose line crew FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance hose line into the structure FORMCHECKBOX At signal from officer FORMCHECKBOX All firefighters on the same side of hose FORMCHECKBOX Whenever possible and safe to do so, leave one firefighter at each 90-degree turn to assist in advancing hose FORMCHECKBOX Approach fire from windward side FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness and monitor for changing conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open nozzle fully and extinguish fire with a direct, indirect, or combination attack as directed by officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Above Ground Fire Attack)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.002Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew before, during, and after ground level attack live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including self-contained breathing apparatus (SCBA) FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate personal alert safety system (PASS) device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prior to entry, bleed air from hose line, check nozzle pattern and pressure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up building / fire conditions, fire location, wind direction, and environment for hazards FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish burning fascia, boxed cornices, or other doorway overhangs as necessary before entering FORMCHECKBOX Ensure that fire is not overhead or behind attack hose line crew FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance hose line into the structure FORMCHECKBOX At signal from officer FORMCHECKBOX All firefighters on the same side of hose FORMCHECKBOX Whenever possible and safe to do so, leave one firefighter at each 90-degree turn to assist in advancing hose FORMCHECKBOX Approach fire from windward side FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance hose line up stairwell to fire floor FORMCHECKBOX If high rise, lay extra hose line in stairwell above the floor to protect the stairwell FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness and monitor for changing conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire with direct, indirect, or combination attack as directed by officer FORMCHECKBOX All firefighters on same side of hose FORMCHECKBOX Approach fire from unburned side FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Below Ground Fire Attack)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.003Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew before, during, and after ground level attack live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including self-contained breathing apparatus (SCBA) FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate personal alert safety system (PASS) device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prior to entry, check nozzle pattern and bleed air from hose line FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up building / fire conditions, fire location, wind direction, and environment for hazards FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish burning fascia, boxed cornices, or other doorway overhangs as necessary before entering FORMCHECKBOX Ensure that fire is not overhead or behind attack hose line crew FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ventilate the basement before entry if possible FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance hose line into the structure FORMCHECKBOX At signal from officer FORMCHECKBOX All firefighters on the same side of hose FORMCHECKBOX Whenever possible and safe to do so, leave one firefighter at each 90-degree turn to assist in advancing hose FORMCHECKBOX Approach fire from windward side FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance hose line down stairwell into the basement FORMCHECKBOX Deploy enough hose at top of stairs to reach and extend into basement FORMCHECKBOX Evaluate fire conditions including stability of stair-well prior to advancing FORMCHECKBOX Coordinate attack with ventilation FORMCHECKBOX Maintain contact with other firefighters FORMCHECKBOX Advance down stairwell quickly to limit exposure to heated gases and smoke FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness and monitor for changing conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire with direct, indirect, or combination attack as directed by officer FORMCHECKBOX All firefighters on same side of hose FORMCHECKBOX Approach fire from unburned side FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Direct Attack Method)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.004Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the direct attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including SCBA FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate PASS device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Select the proper attack hose line and nozzle based on the location and size of the fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Deploy and advance uncharged hose line as directed by supervisor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don SCBA face piece, activate air supply, and activate PASS device when attack hose line is in place FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Signal pump operator when ready for water FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open nozzle to purge air, ensure that water has reached the nozzle, and then close the hose line FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX When ordered, enter the structure and advance to the seat of the fire while crouching or crawling, extinguishing any fires that are encountered FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool hot gasses overhead as needed when accessing a shielded fire using short applications of water fog FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Using a straight or solid stream or a narrow fog pattern, direct the water onto the base of the fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Observe fire conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shut off nozzle when fire is extinguished FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Combination Attack Method)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.005Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the combination attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including SCBA FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate PASS device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Select the proper attack hose line and nozzle based on the location and size of the fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Deploy and advance uncharged hose line as directed by supervisor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don SCBA face piece, activate air supply, and activate PASS device when attack hose line is in place FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Signal pump operator when ready for water FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open nozzle to purge air, ensure that water has reached the nozzle, select correct stream pattern, and close the nozzle FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX When ordered, enter the structure and advance toward the seat of the fire while crouching or crawling, extinguishing any fires that are encountered FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool hot gasses overhead as needed when accessing a shielded fire using short applications of water fog FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX When in place, open nozzle and direct fog pattern toward the upper edge of the fire at the ceiling FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Use T, Z, or O pattern, moving the fire stream from high to low FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shut off the nozzle when the room begins to darken FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Apply water using the direct attack method as needed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shut off nozzle when fire is extinguished FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStructure Fire (Indirect Attack Method)JPR(s)NFPA 1001 Standard, 2013 Edition 6.1.1, 6.1.2, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.006Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the indirect attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don appropriate PPE, including SCBA FORMCHECKBOX Connect SCBA face piece to regulator FORMCHECKBOX Activate PASS device FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure PPE and SCBA have been checked by safety officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Select the proper attack hose line and nozzle based on the location and size of the fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Deploy and advance uncharged hose line as directed by supervisor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Don SCBA face piece, activate air supply, and activate PASS device when attack hose line is in place FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Signal pump operator when ready for water FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open nozzle to purge air, ensure that water has reached the nozzle, select correct stream pattern, and close the nozzle FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX When ordered, enter the structure and advance toward the seat of the fire while crouching or crawling, extinguishing any fires that are encountered FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool hot gasses overhead as needed when accessing a shielded fire using short applications of water fog FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX When in place, open nozzle and direct fog pattern toward the ceiling and upper area of the walls FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Close the interior door to the room allowing the steam to develop. Crack the door to observe the conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Continue to apply water to the compartment linings (walls and ceiling) until fire is reduced FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shut off nozzle when fire is extinguished FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointPortable Fire ExtinguishersJPR(s)NFPA 1001 Standard, 2013 Edition 5.3.16Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.007Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using a portable fire extinguisher before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to extinguish fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up fire, ensuring that it is safe to fight with an extinguisher FORMCHECKBOX Note: Make sure the extinguisher is the appropriate type for the class of fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Check that the extinguisher is properly charged FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pull pin at the top of extinguisher to break the inspection band FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Test to ensure proper operation FORMCHECKBOX Point nozzle horn in safe direction FORMCHECKBOX Discharge very short burst FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Carry the extinguisher to within stream reach of fire FORMCHECKBOX Escape route identified FORMCHECKBOX Upright FORMCHECKBOX Upwind of fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aim nozzle toward base of fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Discharge extinguishing agent FORMCHECKBOX Squeeze handle FORMCHECKBOX Sweep slowly back and forth across entire width of fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cover entire area with (water, dry chemical, or CO2 as selected per the note in Step 1) until the fire is extinguished FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Back away from the area FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate completion of assigned task to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Tag the extinguisher for recharge and inspection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointTrash Container FireJPR(s)NFPA 1001 Standard, 2013 Edition 5.3.8Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.008Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to extinguish fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Set nozzle flow to a straight stream FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Open nozzle fully, briefly, and aim stream to side to test fog pattern and expel air FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up environment for hazards FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance to trash container from uphill and upwind FORMCHECKBOX Keep the stream between the container and any exposures FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Check for threat to exposures and cool as necessary FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool the outside of the container FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attack the fire with a medium fog pattern until it is knocked down FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Perform overhaul FORMCHECKBOX Firefighter #2: Break up material and probe with appropriate tool for hot spots FORMCHECKBOX Firefighter #1: Extinguish hot spots FORMCHECKBOX Do not enter container and avoid placing head into or over any openings FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate completion of assigned task to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointStacked or Piled Materials FireJPR(s)NFPA 1001 Standard, 2013 Edition 5.3.8Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.009Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to extinguish fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up environment for hazards FORMCHECKBOX Identify and verbalize collapse zone FORMCHECKBOX Work outside of collapse zone FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Check nozzle pattern and bleed air from hose line FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Check for threat to exposures and cool as necessary FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance to position to make fire attack FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire with straight stream FORMCHECKBOX At directions of officer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Overhaul debris using appropriate tool FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate completion of assigned task to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointGround Cover FireJPR(s)NFPA 1001 Standard, 2013 Edition 5.3.19Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.010Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up environment for hazards FORMCHECKBOX Identify and verbalize safe zones and escape routes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Position at perimeter of hot zone and approach from the burned area (black) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Approach flame edge and apply water with hand line or extinguisher or use hand tools FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire FORMCHECKBOX Maintain communication with officer FORMCHECKBOX Monitor weather FORMCHECKBOX Monitor fire and smoke conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mop up hot spots FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Exit hazard area to safe area FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointPassenger Vehicle FireJPR(s)NFPA 1001 Standard, 2013 Edition 5.3.7Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.011Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ensure vehicle is secure, chock wheels if necessary FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lay out attack line for a fire attack FORMCHECKBOX Use appropriate PPE including SCBA FORMCHECKBOX Select appropriate hose line and nozzle FORMCHECKBOX Select appropriate hand tool(s) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Charge attack line FORMCHECKBOX Bleed air from hose line FORMCHECKBOX Select appropriate stream pattern FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Advance attack line to vehicle FORMCHECKBOX Approach at a 45-degree angle from upwind and uphill, if possible FORMCHECKBOX Size up scene for hazards FORMCHECKBOX Use fog pattern for personnel protection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish any fire under vehicle or in line of approach. FORMCHECKBOX Use a narrow fog pattern or straight stream for attack FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire in passenger compartment FORMCHECKBOX Break window to gain entry and ventilate FORMCHECKBOX Use a narrow fog pattern or straight stream for attack FORMCHECKBOX Check for victims FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire in engine compartment FORMCHECKBOX Approach from side of vehicle FORMCHECKBOX Open hood at corner using tool such as a Halligan FORMCHECKBOX Use a narrow fog pattern or straight stream for attack FORMCHECKBOX When possible, open hood using latch and prop open FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointPassenger Vehicle Fire (continued)JPR(s)NFPA 1001 Standard, 2013 Edition 5.3.7Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.011Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew before, during, and after ground level attack live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFExtinguish fire in trunk FORMCHECKBOX Approach from side of vehicle FORMCHECKBOX Knock out locking mechanism and open latch FORMCHECKBOX Open trunk and prop open FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Overhaul hidden and smoldering fires FORMCHECKBOX Preserve fire cause evidence FORMCHECKBOX Extinguishment is complete-no hidden or smoldering fires remain FORMCHECKBOX All other hazards such as leaking fuel addressed FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointIgnitable Liquid FiresJPR(s)NFPA 1001 Standard, 2013 Edition 6.3.1, 6.3.2Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.012Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up incident scene for hazards FORMCHECKBOX Fire conditions FORMCHECKBOX Type of fuel FORMCHECKBOX Hot metal FORMCHECKBOX Wind conditions FORMCHECKBOX Escape route FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Verify foam type and concentration are appropriate for fuel and fire conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Verify attack line is functioning and ready for attack FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extend hose line to point of fire attack. FORMCHECKBOX Upwind and uphill FORMCHECKBOX Able to apply stream as needed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extinguish fire by applying foam solution as directed (by one of the following methods): FORMCHECKBOX Rain-Down Method:Direct foam stream into the air above the fire or spill so that foam floats gently down onto surface of fuelMaintain stream as foam spreads across surface of fuelFor small fires-Sweep gently back and forthFor large fires-Direct the stream to one location and allow foam to float out from that pointApply foam until it spreads across the entire surface of fuel and extinguishes the fire FORMCHECKBOX Bank-Down MethodDirect foam stream onto nearby elevated object; allow the foam to run down onto surface of fuelMaintain stream as foam spreads across surface of fuelApply foam until it spreads across entire surface of fuel and extinguishes fire FORMCHECKBOX Roll-on MethodDirect foam stream on the ground near front edge of fire so that foam rolls across surface of fuelMaintain stream as foam rolls across surface of fuelApply foam until it spreads across entire surface of fuel and extinguishes fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailOHIO DEPARTMENT OF PUBLIC SAFETYLIVE FIRE TRAINING OPERATIONS LEVEL INSTRUCTOROPERATIONS LEVEL INSTRUCTORLIVE FIRE PRACTICAL SKILL EVALUATIONTeaching PointPressurized Flammable Gas Container FiresJPR(s)NFPA 1001 Standard, 2013 Edition 6.3.3Reference SourceIFSTA* Essentials of Fire Fighting and Fire Department Operations, 6th EditionSkill No.013Evaluator’s InstructionsIt shall be the responsibility of the instructor candidate to coordinate actions of the fire attack crew using the most appropriate attack method before, during, and after live fire evolution.Candidate DirectiveUsing the information, buildings / props, equipment / apparatus, and personnel provided, Instructor candidate shall properly coordinate all fireground activities of the fire attack crew in accordance with NFPA 1403 and knowledge obtained in “Live Fire Training-Operations Level” training class.PERFORMANCE STEPSTEST RETEST The instructor candidate shall ensure the following actions are taken:PFPFWearing appropriate PPE, confirm order with Incident Commander (IC) to attack fire FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Size up incident scene for hazards FORMCHECKBOX Fire conditions FORMCHECKBOX Type of fuel FORMCHECKBOX Integrity of container FORMCHECKBOX Wind conditions FORMCHECKBOX Escape route and safe haven FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Deploy hand lines FORMCHECKBOX Bleed air from hose lines FORMCHECKBOX Ensure adequate hose line to reach container FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool cylinder or storage tank FORMCHECKBOX Apply straight stream to container FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extend hose lines to isolate control valve FORMCHECKBOX Approach upwind and uphill FORMCHECKBOX Approach container from the side FORMCHECKBOX Push flame away from valve with fog stream (30 degree pattern)Note: If team is unable to push flame away from the valve, immediately withdraw to a safe location and continue to cool the container FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain situational awareness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Close control valve. FORMCHECKBOX Shut valve completely FORMCHECKBOX Report to officer that control valve is closed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cool container from a safe distance. FORMCHECKBOX Withdraw hose lines FORMCHECKBOX Apply straight stream to container FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicate effectiveness / ineffectiveness of attack to Incident Commander FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRST EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailSECOND EVALUATOR (Print Name) FORMTEXT ?????SKILL TEST DATE FORMTEXT ?????Overall Skill Sheet Score FORMCHECKBOX Pass FORMCHECKBOX FailWe attest that the practical skills listed on the above pages have been met and that all information provided is true and accurate to the best of our knowledge. We hereby give permission to the Ohio Department of Public Safety, Division of Emergency Medical Services to verify any of the above information.CANDIDATE SIGNATURE XPRINT CANDIDATE NAME FORMTEXT ?????DATE FORMTEXT ?????INSTRUCTOR TRAINER SIGNATURE XPRINT INSTRUCTOR TRAINER NAME FORMTEXT ?????DATE FORMTEXT ?????PROGRAM DIRECTOR SIGNATURE XPRINT PROGRAM DIRECTOR NAME FORMTEXT ?????DATE FORMTEXT ????? ................
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