Form SMI 3B Time-Distance Motor Skill Performance Retest - North Carolina

Form SMI3B or the "Time-distance Motor Skill Performance Retest" is a form issued by the North Carolina Department of Justice.

The form was last revised in September 19, 2016 and is available for digital filing. Download an up-to-date Form SMI3B in PDF-format down below or look it up on the 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 3B (Rev. 9.19.16)
*RETEST*
TIME-DISTANCE MOTOR SKILL PERFORMANCE RETEST
THIS FORM SHALL BE USED FOR ALL TIME-DISTANCE RETESTS
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 Full Name _______________________________________________________________________________________
Law Enforcement Agency _________________________________________________________________________________
Date of Birth __________________________________ Social Security Number __________________________________
Email Address _______________________________________________________________________
Date of Original Test _____________________________________________________________________________________
Description of Time-Distance Instrument
Manufacturer: ________________________________________
Model:
________________________________________
INSTRUCTOR INITIALS AS TRAINEE PERFORMS CORRECTLY ON EACH STEP
Start Time*
A.
The trainee shall identify to the instructor each component
______________
or module of the Time-Distance Instrument named above.
B.
The trainee shall identify and explain to the instructor all
______________
controls, indicators and adjustments and the individual
purpose and functions of each for the Time-Distance Instrument
named above (without power).
C.
The trainee shall perform instrument accuracy test [(Instructor initials)enters readout on 2 & 4].
1.
Calibration number input
_________
3.
Time input
__________ / _________
2.
Distance readout after calibration #
_________
4
MPH readout
__________ / _________
calibration (within 1/4 of 1%)
(within 1%)
* Deviation
_____________
D.
Road test of 25 clocks with no error in excess of + (plus-minus) 2 mph on any specific clocking.
Trainee disregarded clocks _________________________________ (maximum of five allowed during retest).
Total Sign-off and Calibration Time __________
(CONTINUED ON BACK)
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 3B (Rev. 9.19.16)
*RETEST*
TIME-DISTANCE MOTOR SKILL PERFORMANCE RETEST
THIS FORM SHALL BE USED FOR ALL TIME-DISTANCE RETESTS
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 Full Name _______________________________________________________________________________________
Law Enforcement Agency _________________________________________________________________________________
Date of Birth __________________________________ Social Security Number __________________________________
Email Address _______________________________________________________________________
Date of Original Test _____________________________________________________________________________________
Description of Time-Distance Instrument
Manufacturer: ________________________________________
Model:
________________________________________
INSTRUCTOR INITIALS AS TRAINEE PERFORMS CORRECTLY ON EACH STEP
Start Time*
A.
The trainee shall identify to the instructor each component
______________
or module of the Time-Distance Instrument named above.
B.
The trainee shall identify and explain to the instructor all
______________
controls, indicators and adjustments and the individual
purpose and functions of each for the Time-Distance Instrument
named above (without power).
C.
The trainee shall perform instrument accuracy test [(Instructor initials)enters readout on 2 & 4].
1.
Calibration number input
_________
3.
Time input
__________ / _________
2.
Distance readout after calibration #
_________
4
MPH readout
__________ / _________
calibration (within 1/4 of 1%)
(within 1%)
* Deviation
_____________
D.
Road test of 25 clocks with no error in excess of + (plus-minus) 2 mph on any specific clocking.
Trainee disregarded clocks _________________________________ (maximum of five allowed during retest).
Total Sign-off and Calibration Time __________
(CONTINUED ON BACK)
TIME-DISTANCE MOTOR SKILL PERFORMANCE RETEST
FORM SMI 3B (Rev. 9.19.16) PAGE 2
RETEST
RETEST
_________________________________________________
__________________________________________________
CONFIGURATION
CONFIGURATION
Keep Time*
[5 consecutive clocks] Init.
Keep Time*
[5 consecutive clocks] Init.
TARGET
PATROL
MPH
TARGET
PATROL
MPH
VEHICLE
VEHICLE
ERROR
VEHICLE
VEHICLE
ERROR
Total Time
Total Time
TOTAL
TOTAL
ERROR
ERROR
* ERRORS *
1.
Following Clocks
2.
Approach from Rear Clocks
“T” Intersection Clocks
3.
4.
Meeting Clocks
5.
Parked Pre-Measured Clocks
TOTAL ERROR ON 25 CLOCKS
Total Time on ORIGINAL Test
__________
Total RETEST Time
__________
Pass or Fail Testing Time
__________
Total Error on 25 clocks not to exceed 18.7 mph or an
average error of not more than .750. No one error in
excess of + 2 mph.
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’S NAME (PRINT) ____________________________________________________________________
INSTRUCTOR'S SIGNATURE _____________________________ CERTIFICATION NO.______________________
INSTRUCTOR’S NAME (PRINT) ____________________________________________________________________
INSTRUCTOR'S SIGNATURE _____________________________ CERTIFICATION NO.______________________
THE TRAINEE IS ONLY ALLOWED TO RETEST ON THE SPECIFIED NUMBER OF CONFIGURATIONS AS DESCRIBED
BELOW. IF THE TRAINEE FAILS SECTIONS A, B, OR C OF THIS RETEST FORM (IF APPLICABLE) “OR” IF THE TRAINEE’S
TOTAL ERROR ON THE FIVE (COMBINED) CONFIGURATIONS STILL EXCEEDS 18.7 MPH AFTER THIS ALLOWABLE
RETEST, THE STUDENT HAS FAILED THE MOTOR SKILL PERFORMANCE RE-EXAMINATION AND WILL NOT BE
RECOMMENDED FOR CERTIFICATION AND SHALL ENROLL AND COMPLETE A SUBSEQUENT COURSE OFFERING IN ITS
ENTIRETY BEFORE FURTHER EXAMINATION MAY BE PERMITTED.
1.
On sections A, B, or C of the original test form.
On as many as two (2) different clocking configurations in which the clocking error is more than + 2 mph, “OR”
2.
3.
On as many as two (2) different clocking configurations in which the average error exceeds .750 (3.75 mph).
(If overall error exceeds 18.7 mph), “OR“
4.
On one (1) clocking configuration in which the clocking error is more than + 2 mph and one (1) clocking configuration
in which the average error exceeds .750 (3.75 mph)
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