CDC 10351W

Fire & Life Safety Educator I

Performance Test Supplement

Extension Course Program (A4L)

Air University
Air Education and Training Command
Acknowledgement
Preparation of this supplement was aided through the cooperation and courtesy of the International Fire
Service Training Association (IFSTA). IFSTA furnished technical materials utilized to develop this
training product. Permission to use the information from IFSTA is gratefully acknowledged. In
accordance with the copyright agreement, distribution of this supplement is limited to U.S. Government
personnel.

ii Fire and Life Safety Educator I Performance Test Supplement

Table of Contents

General Guidance .......................................................................................................................... iv

Evaluator Orientation .................................................................................................................... v
Grading Information ..................................................................................................................... vi
Performance Test Summary Sheet ............................................................................................... 1
Skills Test #1 Administration ........................................................................................................ 3
NFPA Standard 1035, Chapter 4, paragraphs 4.2.1, 4.2.2, 4.2.3, 4.2.4 ____________________________________ 3
Task Specific Instructions and Information _______________________________________________ 3
Skills Test #1 Checklist ______________________________________________________________ 4
Skills Test #2 Planning and Development .................................................................................... 7
NFPA Standard 1035, Chapter 4, paragraphs 4.3.1 ___________________________________________________ 7
Task Specific Instructions and Information _______________________________________________ 7
Skills Test #2 Checklist ______________________________________________________________ 8
Skills Test #3 Education and Implementation ............................................................................. 9
NFPA Standard 1035, Chapter 4, paragraphs 4.4.1, 4.4.2, 4.4.3, 4.4.4, 4.4.5, 4.4.6, 4.4.7 _____________________ 9
Task Specific Instructions and Information _______________________________________________ 9
Skills Test #3 Checklist _____________________________________________________________ 10
Skills Test #4 Evaluation and Testing......................................................................................... 15
NFPA Standard 1035, Chapter 4, paragraphs 4.5.1, 4.5.2 _____________________________________________ 15
Task Specific Instructions and Information ______________________________________________ 15
Skills Test #4 Checklist _____________________________________________________________ 16
Fire and Life Safety Educator I Performance Test Record ..................................................... 17

Fire and Life Safety Educator I Performance Test Supplement iii

Performance Test Information
General Guidance
This performance test supplement is based on the 2015 Edition of NFPA 1035; Standard on Fire and Life
Safety Educator, Public Information Officer, Youth Firesetter Intervention Specialist and Youth Firesetter
Program Manager Professional Qualifications and provides the detailed performance test checklist items
required for candidate testing. Performance tests shall not be conducted until the candidate has
successfully completed the academic portion of the course by passing the End of Course final exam at an
Air University approved test control facility (TCF). However, it is strongly encouraged that this
supplement and the checklist it contains be used during the normal course of study. Candidates may
practice the performance tests at any time during study and up until testing is conducted. Practice is highly
encouraged.
There are no prerequisites for obtaining DOD certification to Fire and Life Safety Educator I.
Evaluators must be DOD, IFSAC or Pro Board certified at Fire Instructor II level or higher.
This particular course uses several skills test. Within each skills test there are one or more tasks meeting
the test objectives (NFPA line items). A “Task Summary” precedes each skills test checklist identifying
all the evaluated task associated with the test. This sheet lists the NFPA line items evaluated, the setting
and tools/equipment needed for the listed tasks, and any evaluator guidance necessary for the task(s).
Evaluators should review the checklist paying specific attention to any “Evaluator Guidance”.
Scenarios developed should be as realistic and complete as possible. A minimum of two scenarios must be
developed for each performance test requiring one. This allows for the candidate to retest in case of first
time failure. Additionally, scenarios should be changed periodically to dissuade future candidates from
gaining an unfair advantage or allowing for test compromise.
Remember, official performance test notifications must be made at least ten (10) days prior to the actual
performance test or the candidate’s performance test results will not be accepted by the DOD
Administrative Center. Your performance test notifications must be made using the following web site.
http://www.dodffcert.com/performance/notify.cfm. For specific program guidance see DOD Manual
6055.06, DOD Fire and Emergency Services Certification Program.

iv Fire and Life Safety Educator I Performance Test Supplement

Performance Test Information
Evaluator Orientation
You should read and understand the following orientation information before entering the specific skill
station you will be evaluating. If there is any information within this orientation that you do not
understand, you should contact the examination coordinator for clarification. We would like to thank you
for donating your valuable time to assist with the evaluation of candidates in the practical examination.
Your role as a skill station evaluator is critically important. You are to serve as an observer and recorder
of the candidate's actions based on the criteria listed on the score sheet. There are a number of ways to
successfully perform a skill. You should always remember that the way you were taught to perform a skill
is not the only correct way to perform the skill. The ultimate criterion for successful completion of a skill
is: "Was the final outcome met for the parameters set?"
This is a formal examination and not a teaching situation. We discourage excessive dialogue between the
evaluator and the candidate. Peripheral or "nice to know" areas of should not be discussed. Situations or
questions that require you to demonstrate a procedure should be avoided. You should not ask leading
questions. Do not condemn or condone a candidate's actions by expression, gesture, tone of voice, or
attitude. Often, candidates interpret a word or action delivered in jest as being indicative of pass or fail, a
value judgment, or a non-caring attitude. Pay special attention to verbal and non-verbal language.
The reason you were asked to be an evaluator for this station is that your expertise adds to the credibility of
the examination and gives you the knowledge to ask the candidates related questions to substantiate or
define an action. If qualifying questions are necessary, they should be asked at the end of the station. At
no time should you discuss any phase of the candidate's performance with the candidate.
Candidates are allowed to perform each skill once. If they appear overly nervous when first starting the
exam, you may stop them and allow them to collect themselves before starting again. However, once a
candidate initiates a course of action the candidate must be evaluated on the merits of that singular
performance, as would happen in the field. You must provide qualifying information in the comments
section of the score sheet for any performance that is identified as a mandatory failure item.
Visitors are not allowed in the testing area while testing is being conducted. The examination coordinator
may be in the testing area if they are not obstructive to the testing.
You must document in the comments section the reason you marked a mandatory failure item. Additional
comments are welcome, but remember to be specific. Instead of writing "He did a poor job", write exactly
what the candidate did right or wrong. At no time should you discuss the performance with the candidate.
You should never condemn or condone the candidate's actions by verbal or nonverbal means.
If the candidate reaches the time limit indicated on the score sheet before completing the procedure, you
must stop the candidate and direct him/her to return to the staging area and wait for instructions to report to
the next station. All tasks not completed should be scored a zero in the "points awarded" column.
Be very aware of the importance of consistency in giving instructions, setting up scenarios, and making
and recording observations. Every effort should be made to ensure that all details of the examination
scenario are identical for each candidate. Be aware of your own fatigue and if necessary take a break after
notifying the examination coordinator.
You should have received individual written instructions concerning the specific skill and/or skill station
you will be evaluating. If you do not understand any part of these instructions, do not start the evaluation
process. Contact the examination coordinator for clarification.
It is important also to understand the grading process used during the evaluation. Additional information
on grading the skills test is provided on the next page.

Fire and Life Safety Educator I Performance Test Supplement v

Performance Test Information
Grading Information
The following grading criteria will be used to evaluate and determine the pass/fail status of a candidate.
Each of the performance test checklists contains an attainment standard. In this particular course the
attainment standards are set at approximately 80% using an “X out of X” format while also containing a
time limit. For example, an attainment standard may read, “Successful completion of at least 15 out of 18
items within 90 minutes.”
If for some reason a particular element/step or standard cannot be completed and the candidate’s
installation cannot simulate or create the item, then the evaluator may mark the item “Not Applicable”
(N/A). The evaluator must then re-adjust the score by multiplying the remaining checklist items by .80 to
determine the number correct required. For example, a performance test requires that 12 out of 15 items
be successfully completed and 2 of the 15 items are marked N/A then the evaluator must multiply the
remaining 13 items by .80 (13 x .80 = 10.4 or 11). The new required minimum passing score is now 11
out 13 items.
There are a total of four (4) skills performance test encompassing 13 separate tasks. Candidates must
successfully complete and pass 11 of the 13 task with no more than one (1) task failure within any skills
performance test.
--AND--
Where the Standard/Element/Step on the Skills Test checklist is given a rating, the following criteria will
be also be used to determine the pass/fail status of a candidate.
Critical (C) - This rating has been assigned to items, which, if omitted or performed incorrectly, would
result in severe injury to, or death of, an individual. Should a firefighter fail to perform any one item
rated as Critical (C), the firefighter would be unsuccessful in demonstrating the required proficiency level
for that standard.
Major (M) - This rating refers to any item that is very important to the general safety of personnel and
the successful completion of the evolution. Should a firefighter fail to perform any three items rated as
Major (M), the firefighter would be unsuccessful in demonstrating the required proficiency level for that
standard.
General - This rating although there is not symbol, has been given to all remaining items that in
combination are relevant to the successful completion of the evolution. Should a firefighter fail to
perform any four items rated as General, the firefighter would be unsuccessful in demonstrating the
required proficiency level for that standard.
Should a firefighter fail to perform any combination of Major or General rated items resulting in a sum
total of four, the firefighter would be unsuccessful in demonstrating the required proficiency level for that
standard.

vi Fire and Life Safety Educator I Performance Test Supplement

Competency Overview
Performance Test Summary Sheet
Skills Test #1 – Administration
Task #1. Document fire and life safety educational activities.
Task #2. Prepare activity reports.
Task #3. Maintain a work schedule.
Task #4. Identify community resources.
Skills Test #2 – Planning and Development
Task #5. Identify organizational community partners.
Skills Test #3 – Education and Implementation
Task #6. Select instructional materials specific to the audience and objective.
Task #7. Practice safety during an education activity.
Task #8. Present a lesson following the lesson plan.
Task #9. Adapt a lesson to meet the needs of the audience.
Task #10. Notify the public of a scheduled event.
Task #11. Disseminate information within a specified time.
Skills Test #4 – Evaluation and Testing
Task #12. Administer an evaluation so the lesson outcome is measured.
Task #13. Score an evaluation so the lesson outcome is known.

Fire and Life Safety Educator I Performance Test Supplement 1

Fire and Life Safety Educator I Competencies
Skills Test #1 Administration
NFPA Standard 1035, Chapter 4, paragraphs 4.2.1, 4.2.2, 4.2.3, 4.2.4

Task Specific Instructions and Information

Tasks: Task #1. Document public fire and life safety educational programs, given
appropriate forms or formats, so that all programs are recorded and each element of
the form or format is addressed.

Task #2. Prepare activity reports, given specific forms or formats and information
on activities, so that all components of the forms or format reflect correct
information specific to the activity.

Task #3. Maintain a work schedule, given a list of events, activity requests, pre-
activity requirements and time allotments, so that all activities are scheduled and
completed without conflict.

Task #4. Identify community resources, services and organizations, given a current
list of resources, organizations and identified needs.

Setting: Fire Department Classroom or equivalent.

Tools/ Paper, writing instruments or computer, applicable reference material, fire

Equipment: department’s SOP/SOG’s and appropriate forms.

Attainment Task # 1. Successfully complete 4 of 5 steps within 8 hours.

Standard:
Task # 2. Successfully complete all steps within 3 hours.

Task # 3. Successfully complete 4 of 5 steps within 4 hours.

Task # 4. Successfully complete all steps within 2 hours.

Evaluator’s N/A
Guidance:

Fire and Life Safety Educator I Performance Test Supplement 3

Fire and Life Safety Educator I Competencies
Skills Test #1 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
1. Document public fire and life 1. In accordance with the NFPA 1035, the
safety educational programs, candidate:
given appropriate forms or
formats, so that all programs are A. Identified appropriate education activity _____ _____
recorded and each element of the information
form or format is addressed.
B. Scheduled activity with no conflicts _____ _____

C. Identified appropriate forms/format for _____ _____

recording activities

D. Accurately recorded the appropriate _____ _____

activity information on forms

E. Properly completed and submitted _____ _____

activity forms

F. Completed 4 of 5 steps within 8 hours _____ _____

2. Prepare activity reports, given 2. In accordance with the NFPA 1035, the
specific forms or formats and candidate:
information on activities, so that
all components of the forms or A. Identified type of educational activity _____ _____
format reflect correct information and appropriate classification for activity
specific to the activity.
B. Selected appropriate form/format for _____ _____
activity according to policies and
procedures of the AHJ

C. Completed all components of the form _____ _____

with correct information based on the
activity

D. Maintained records IAW local policies _____ _____

and procedures

E. Completed 4 of 4 steps within 3 hours _____ _____

4 Fire and Life Safety Educator I Performance Test Supplement

Fire and Life Safety Educator I Competencies
Skills Test #1 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
3. Maintain a work schedule, given 3. In accordance with the NFPA 1035, the
a list of events, activity requests, candidate:
pre-activity requirements and
time allotments, so that all A. Identified program requests and pre- _____ _____
activities are scheduled and activity requirements
completed without conflict.
B. Selected an appropriate work schedule _____ _____
format/outline

C. Identified work schedule time allotment _____ _____

D. Identified and set proper _____ _____

activity/schedule limitations

E. Completed an appropriate schedule of _____ _____

events

F. Completed 4 of 5 steps correctly in 4 _____ _____

hours

4. Identify community resources, 4. In accordance with the NFPA 1035, the

services and organizations, given candidate:
a current list of resources,
organizations and identified A. Determined the need for community _____ _____
needs. resources

B. Selected the appropriate community _____ _____

resource, service or organization for the
need

C. Referred the public to the appropriate _____ _____

resource

D. Completed 3 of 3 steps within 2 hours _____ _____

Fire and Life Safety Educator I Performance Test Supplement 5

Fire and Life Safety Educator I Competencies
Skills Test #2 Planning and Development
NFPA Standard 1035, Chapter 4, paragraphs 4.3.1

Task Specific Instructions and Information

Tasks: Task #5. Identify partners for addressing fire and life safety issues so that the
information and resources are shared.

Setting: Fire Department Classroom or equivalent.

Tools/ Paper, writing instruments or computer, applicable reference material, fire

Equipment: department’s SOP/SOG’s.

Attainment Task # 5. Successfully complete 7 of 8 steps within 4 hours.

Standard:

Evaluator’s None.
Guidance:

Fire and Life Safety Educator I Performance Test Supplement 7

Fire and Life Safety Educator I Competencies
Skills Test #2 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
5. Identify partners for addressing 5. In accordance with the NFPA 1035, the
fire and life safety issues so that candidate:
the information and resources are
shared A. Identified appropriate community and _____ _____
organizations available

B. Identified appropriate background _____ _____

information for issues needed

C. Determined opportunities for shared

efforts

(1) Networking _____ _____

(2) Coalitions _____ _____
(3) Collaboration _____ _____
(4) Partners _____ _____

D. Identified necessary partners to address _____ _____

issues and share information

E. Identified appropriate partners to share _____ _____

resources

F. Completed 7 of 8 steps within 4 hours _____ _____

8 Fire and Life Safety Educator I Performance Test Supplement

Fire and Life Safety Educator I Competencies
Skills Test #3 Education and Implementation
NFPA Standard 1035, Chapter 4, paragraphs 4.4.1, 4.4.2, 4.4.3, 4.4.4, 4.4.5, 4.4.6, 4.4.7

Task Specific Instructions and Information

Tasks: Task #6. Select appropriate instructional material so that the material is specific to
the audience and objective. Communicate material orally and in writing and manage
time efficiently.

Task #7. Practice and maintain safety during a fire and life safety education activity.

Task #8. Present a 20 - 30 minute block of instruction. Communicate orally and in

writing, manage time and multitask.

Task #9. Adapt a lesson plan to meet the audience needs. Communicate orally and
in writing, manage time and multitask.

Task #10. Given a scheduled event, notify the public so the location, date, time and
topic is included.

Task #11. Disseminate educational information so the information reaches the

audience within the specific time.

Setting: Fire Department Classroom or equivalent.

Tools/ Paper, writing instruments or computer, applicable reference material, fire

Equipment: department’s SOP/SOG’s and appropriate forms.

Attainment Task # 6. Successfully complete 5 of 6 steps within 8 hours.

Standard:
Task # 7. Successfully complete 4 of 5 steps within 30 minutes.

Task # 8. Successfully complete 12 of 15 steps within 30 minutes.

Task # 9. Successfully complete 9 of 11 steps within 8 hours.

Task # 10. Successfully complete 7 of 8 steps within 8 hours.

Task # 11. Successfully complete 7 of 9 steps within 8 hours.

Evaluator’s For Task 11.F, have candidate disseminate information by 2 of the 4 methods.
Guidance:

Fire and Life Safety Educator I Performance Test Supplement 9

Fire and Life Safety Educator I Competencies
Skills Test #3 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
6. Select appropriate instructional 6. In accordance with the NFPA 1035, the
material so that the material is candidate:
specific to the audience and
objective. Communicate A. Selected instructional material including _____ _____
material orally and in writing and props and equipment appropriate to the
manage time efficiently. activity objective

B. Selected proper amounts of information _____ _____

to meet the learning objective

C. Selected material that appropriately _____ _____

explain the actions learners are to take

D. Selected material that is appropriate to _____ _____

the audience’s learning level and free of
bias

E. Selected instructional material that is of _____ _____

appropriate length or duration for the
lesson taught and the audience

F. Explained why the material was _____ _____

selected, the audience learning level,
material appeal and visual aids

G. Completed 5 of 6 steps within 8 hours _____ _____

7. Practice and maintain safety 7. In accordance with the NFPA 1035, the
during a fire and life safety candidate:
education activity.
A. Ensured classroom and equipment was _____ _____
set up with safety hazards identified,
eliminated and exits clear

B. Verified classroom was not overcrowded _____ _____

C. Established appropriate safety zone _____ _____

around equipment and props

D. Explained proper safety requirements, _____ _____

i.e., lifting techniques or stay upwind

E. Ensured appropriate number of _____ _____

personnel to provide adequate
supervision

F. Completed 4 of 5 steps within 30 _____ _____

minutes

10 Fire and Life Safety Educator I Performance Test Supplement

Fire and Life Safety Educator I Competencies
Skills Test #3 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
8. Present a 20 - 30 minute block of 8. In accordance with the NFPA 1035, the
instruction. Communicate orally candidate:
and in writing, manage time and
multitask A. Matched the appropriate instructional _____ _____
method to the lesson given

B. Created a proper opening _____ _____

C. Properly organized the presentation _____ _____

D. Motivated audience and created an _____ _____

interest to learn

E. Questioned the audience to ascertain _____ _____

knowledge of the subject matter

F. Clearly stated the objective _____ _____

G. Managed time and multitasked _____ _____

appropriately

H. Dressed appropriately for audience and _____ _____

topic

I. Maintained eye contact with students _____ _____

J. Ensured voice tone, pitch and _____ _____

modulation is appropriate

K. Used proper gestures _____ _____

L. Developed rapport with students _____ _____

M. Properly controlled distractions _____ _____

N. Properly used audio visual equipment _____ _____

O. Established an appropriate _____ _____

summary/closure and reviewed key
procedures

P. Completed 12 of 15 steps within 30 _____ _____

minutes

Fire and Life Safety Educator I Performance Test Supplement 11

Fire and Life Safety Educator I Competencies
Skills Test #3 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
9. Adapt a lesson plan to meet the 9. In accordance with the NFPA 1035, the
audience needs. Communicate candidate:
orally and in writing, manage
time and multitask. A. Ensured adapted instructional material _____ _____
including props and equipment
appropriate to the activity objective

B. Ensured proper amount of information _____ _____

given to meet the learning objective

C. Ensured adapted material appropriately _____ _____

explains the actions learners are to take

D. Ensured adapted material is appropriate _____ _____

to the audience’s learning level and free
of bias

E. Ensured adapted instructional material is _____ _____

of appropriate length or duration for the
lesson taught and the audience

F. Explained

(1) Reason material was selected _____ _____

(2) Audience’s learning level _____ _____
(3) Reason for visual aids and props _____ _____

G. Developed to meet the learning objective

(1) Cognitive _____ _____

(2) Psychomotor _____ _____
(3) Affective _____ _____

H. Completed 9 of 11 steps within 8 hours _____ _____

10. Given a scheduled event, notify 10. In accordance with the NFPA 1035, the
the public so the location, date, candidate:
time and topic are included.
A. Selected adequate/appropriate publicity _____ _____
method

B. Correctly followed department policies _____ _____

for information dissemination

C. Properly identified local media resources _____ _____

12 Fire and Life Safety Educator I Performance Test Supplement

Fire and Life Safety Educator I Competencies
Skills Test #3 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
10. Continued
D. Created appropriate notification material

(1) Location _____ _____

(2) Date _____ _____
(3) Time _____ _____
(4) Topic _____ _____
(5) Sponsoring agency _____ _____

E. Completed 7 of 8 steps within 8 hours _____ _____

11. Disseminate educational 11. In accordance with the NFPA 1035, the
information so the information candidate:
reaches the audience within the
specific time. A. Identified department legal _____ _____
requirements and policies for
distribution and posting of material

B. Identified distribution methods _____ _____

C. Identified proper venues _____ _____

D. Created a proper timeline for _____ _____

processing information

E. Distributed educational material in a _____ _____

timely manner

F. Correctly identified distribution

methods and properly disseminated
information

(1) Radio _____ _____

(2) Television _____ _____
(3) News release _____ _____
(4) Social Media _____ _____

G. Completed 7 of 9 steps within 8 hours _____ _____

Fire and Life Safety Educator I Performance Test Supplement 13

Fire and Life Safety Educator I Competencies
Skills Test #4 Evaluation and Testing
NFPA Standard 1035, Chapter 4, paragraphs 4.5.1, 4.5.2

Task Specific Instructions and Information

Tasks: Task #12. Administer an evaluation so the lesson outcome is measured.

Task #13. Score an evaluation so the lesson outcome is known.

Setting: Fire Department Classroom or equivalent.

Tools/ Paper, writing instruments or computer, fire department’s SOP/SOG’s and appropriate
Equipment: forms.

Attainment Task # 12. Successfully complete 8 of 9 steps within 8 hours.

Standard:
Task # 13. Successfully complete 5 of 6 steps within 2 hours.

Evaluator’s None
Guidance:

Fire and Life Safety Educator I Performance Test Supplement 15

Fire and Life Safety Educator I Competencies
Skills Test #4 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
12. Administer an evaluation so the 12. In accordance with the NFPA 1035, the
lesson outcome is measured. candidate:

A. Developed a pretest/post test _____ _____

B. Administered a pretest/post test _____ _____

C. Allowed sufficient time for students to _____ _____

take the test

D. Refrained from coaching or providing _____ _____

feedback during testing process

E. Ensured the classroom is appropriate for _____ _____

testing purposes

F. Developed a skills test checklist _____ _____

G. Administered a skills test using the _____ _____

checklist

H. Conducted a survey to determine the _____ _____

audiences attitude/behavior

I. Determined if lesson objectives were _____ _____

met

J. Completed 8 of 9 steps within 8 hours _____ _____

13. Score an evaluation so the lesson 13. In accordance with the NFPA 1035, the
outcome is known. candidate:

A. Properly graded examinations _____ _____

B. Calculated the scores by percentage _____ _____

C. Calculated by the mean of scores _____ _____

D. Interpreted the test results based on test _____ _____

scores and question item analysis

E. Determined Pass/Fail status of students _____ _____

F. Determined if the lesson objectives were _____ _____

met

G. Completed 5 of 6 steps within 2 hours _____ _____

16 Fire and Life Safety Educator I Performance Test Supplement

Fire and Life Safety Educator I Performance Test Record

INSTRUCTIONS: This form must be completed and kept on file. A copy of this form is also required to
be submitted with the candidate’s certification package.

Performance Test Ref # ______________ Date of Evaluation __________________

Candidate’s Name __________________________________ SSN ______________________

Evaluator’s Name __________________________________ SSN ______________________

The candidate has PASSED/FAILED the Certification Title Performance Tests for the stations marked
below:

SKILLS TEST PASSED FAILED

1 – Administration ________ ________

2 – Planning and Development ________ ________

3 – Education and Implementation ________ ________

4 – Evaluation ________ ________

If candidate has failed the performance evaluation, provide the following information:
(Use additional sheets, if necessary)

Objective(s):

Reason(s) for failure:

Candidate’s Signature _________________________________________________

Evaluator’s Signature _________________________________________________

"FOUO. This document contains information exempt from mandatory disclosure under the FOIA.
Exemption 5 U.S.C. 552(b)(6) applies. This information is also protected by the Privacy Act of 1974
and must be safeguarded from unauthorized disclosure."