Lead Evaluator Acknowledgement

COURSE INFORMATION
Please submit the information for the Lead Evaluator Awareness. Note: Hazmat Awareness and Technical Rescue Awareness Certifications or Retests do not require lead evaluator acknowledgement.

*1. Lead Evaluator Information

*Legal First Name

Preferred First Name

*Middle Name (if you don’t legally have a middle name, please enter “NMN”)

*Last Name

Suffix

PSID Number (Correct Format: XXXX-XXXX)

PERSONAL Email Address:

Retype Email Address:

Cell Phone Number Correct Format: (XXX) XXX-XXXX ()

*2. Fire Training Course Number

*3. Fire Training Course Name

4. List additional (maximum 5) evaluators who assisted you, if any, otherwise skip to the next question: (First & Last name, PSID #, if known)

 
  First Name Last Name PSID
1.
2.
3.
4.
5.

*5. Student Names - First & Last Name & PSID #'s
*Example:

 
  First Name Middle Name Last Name PSID
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

6. If you have additional students' names to submit, please indicate YES below:

*7. On what date did those students successfully complete all practical skills associated with the Certification being applied for? (MM/DD/YYYY)

*8. Do you swear under the penalty of perjury that the answers given in this survey are a complete, accurate and truthful account of your actions as a lead evaluator as it relates to the conduct of the practical skills associated with the certification being applied for by the students as prescribed by the Indiana Board of Firefighting Personnel Standards and Education?
Yes
No