Form SMI 4 Time-Distance Motor Skill Performance Test (Supplement) - North Carolina

Form SMI4 is a North Carolina Department of Justice form also known as the "Time-distance Motor Skill Performance Test (supplement)". The latest edition of the form was released in April 10, 2014 and is available for digital filing.

Download a PDF version of the Form SMI4 down below or find it on North Carolina Department of Justice Forms website.

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CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
C
J
S
D
RIMINAL
USTICE
TANDARDS
IVISION
P
O
D
149, R
, NC 27602
OST
FFICE
RAWER
ALEIGH
T
: (919) 661-5980
ELEPHONE
FORM SMI 4 (Rev. 4.10.14)
T
-D
M
S
P
T
(S
)
IME
ISTANCE
OTOR
KILL
ERFORMANCE
EST
UPPLEMENT
Supplement to Form SMI 3 to obtain 2 sets of 6 consecutive speed estimates with a total error on 12 speed estimates not to exceed 42 mph or an average
error of not more than 3.5. (One set stationary and one set moving). No one error in excess of + 12 mph. If retest if necessary, use form SMI 2D.
THIS FORM IS NOT TO BE USED AS A SUPPLEMENT TO THE SMI 1 OR 2 FORMS.
THIS FORM IS TO BE USED ONLY DURING THE TIME-DISTANCE OPERATOR OR INSTRUCTOR COURSES.
The Social Security Number is used to make positive identification of applicant and/or law enforcement personnel. DISCLOSURE IS VOLUNTARY.
However, failure to provide this information may result in a delay in the processing of application materials and may result in inaccurate records being
assigned to you.
Trainee Name ____________________________________ Email Address ________________________________________
DOB _________ Agency ___________________________________ SSN _________________ Date __________________
Speed Measuring Instrument Used to Determine Target Speed ____________________________________________________
STATIONARY
MOVING-OPPOSITE DIRECTION
Keep Time*
[6 consecutive clocks] Init.
Keep Time*
[6 consecutive clocks] Init.
RADAR TARGET
TRAINEE
MPH
RADAR TARGET
TRAINEE
MPH
SPEED
ESTIMATE
ERROR
SPEED
ESTIMATE
ERROR
Total Time
Total Time
TOTAL ERROR
-----------------
TOTAL ERROR
-----------------
RESTART (SAME DAY)
______________________________________________
CONFIGURATION
Keep Time*
[6 consecutive clocks] Init.
RADAR TARGET
TRAINEE
MPH
* ERRORS *
SPEED
ESTIMATE
ERROR
1.
Stationary
2.
Moving-Opposite Direction
TOTAL ERROR ON 12 ESTIMATES
TOTAL TIME OF TESTING ____ __ __
Pass or Fail on Time Allotted __________
Total Error on 12 speed estimates not to exceed 42 mph or an average
error of not more than 3.5. No one error in excess of + 12 mph.
Total Time
TOTAL ERROR
I hereby certify that the above-named trainee
has
has not demonstrated one hundred (100) percent competence in each motor skill or
performance as noted on this form.
Date ________________________
INSTRUCTOR NAME(S) (Print) ______________________________________________________________________
INSTRUCTOR'S SIGNATURE _________________________ CERTIFICATION NO. ________________________
INSTRUCTOR'S SIGNATURE ________________________ CERTIFICATION NO. ________________________
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
C
J
S
D
RIMINAL
USTICE
TANDARDS
IVISION
P
O
D
149, R
, NC 27602
OST
FFICE
RAWER
ALEIGH
T
: (919) 661-5980
ELEPHONE
FORM SMI 4 (Rev. 4.10.14)
T
-D
M
S
P
T
(S
)
IME
ISTANCE
OTOR
KILL
ERFORMANCE
EST
UPPLEMENT
Supplement to Form SMI 3 to obtain 2 sets of 6 consecutive speed estimates with a total error on 12 speed estimates not to exceed 42 mph or an average
error of not more than 3.5. (One set stationary and one set moving). No one error in excess of + 12 mph. If retest if necessary, use form SMI 2D.
THIS FORM IS NOT TO BE USED AS A SUPPLEMENT TO THE SMI 1 OR 2 FORMS.
THIS FORM IS TO BE USED ONLY DURING THE TIME-DISTANCE OPERATOR OR INSTRUCTOR COURSES.
The Social Security Number is used to make positive identification of applicant and/or law enforcement personnel. DISCLOSURE IS VOLUNTARY.
However, failure to provide this information may result in a delay in the processing of application materials and may result in inaccurate records being
assigned to you.
Trainee Name ____________________________________ Email Address ________________________________________
DOB _________ Agency ___________________________________ SSN _________________ Date __________________
Speed Measuring Instrument Used to Determine Target Speed ____________________________________________________
STATIONARY
MOVING-OPPOSITE DIRECTION
Keep Time*
[6 consecutive clocks] Init.
Keep Time*
[6 consecutive clocks] Init.
RADAR TARGET
TRAINEE
MPH
RADAR TARGET
TRAINEE
MPH
SPEED
ESTIMATE
ERROR
SPEED
ESTIMATE
ERROR
Total Time
Total Time
TOTAL ERROR
-----------------
TOTAL ERROR
-----------------
RESTART (SAME DAY)
______________________________________________
CONFIGURATION
Keep Time*
[6 consecutive clocks] Init.
RADAR TARGET
TRAINEE
MPH
* ERRORS *
SPEED
ESTIMATE
ERROR
1.
Stationary
2.
Moving-Opposite Direction
TOTAL ERROR ON 12 ESTIMATES
TOTAL TIME OF TESTING ____ __ __
Pass or Fail on Time Allotted __________
Total Error on 12 speed estimates not to exceed 42 mph or an average
error of not more than 3.5. No one error in excess of + 12 mph.
Total Time
TOTAL ERROR
I hereby certify that the above-named trainee
has
has not demonstrated one hundred (100) percent competence in each motor skill or
performance as noted on this form.
Date ________________________
INSTRUCTOR NAME(S) (Print) ______________________________________________________________________
INSTRUCTOR'S SIGNATURE _________________________ CERTIFICATION NO. ________________________
INSTRUCTOR'S SIGNATURE ________________________ CERTIFICATION NO. ________________________
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