SUBCHAPTER 09I – FORMS FOR CRIMINAL JUSTICE EMPLOYMENT, EDUCATION, AND TRAINING

SECTION .0100‑ FORMS FOR USE IN TRAINING PROGRAMS AND INSTRUCTOR CERTIFICATION

12 NCAC 09I .0101 INSTRUCTOR AND PROFESSIONAL LECTURER CERTIFICATION FORMS

The following Commission-approved forms shall be used by individuals applying for initial or renewal of certification as an instructor or professional lecturer, pursuant to 12 NCAC 09B .0300:

(1) Form F-12, Application for Instructor or Professional Lecturer Certification, shall contain the following information:

(a) name of applicant;

(b) address, phone number, email address, date of birth, age, last four of Social Security Number, and academy ID number;

(d) type of instructor certification applying for;

(e) supporting documents for specific certification sought;

(f) highest education level, school attended, school location, and graduation date;

(g) criminal justice experience;

(h) signature of applicant;

(i) Commission-accredited school taught at, course title, hours taught, course dates, and whether the course was a requirement of Mandatory In-Service Training; and

(j) signature of certifying School Director or In-Service Training Coordinator, school or agency name, phone number, and email address.

(2) Form F-16, Criminal Justice Instructor Evaluation, shall contain the following information:

(a) instructor's name, date of birth, and academy ID number;

(b) evaluator's name and academy ID number;

(d) scores for Instructional Ability and Strategies; and

(e) Presentation Evaluation Criteria.

History Note: Authority G.S. 17C‑6;

Eff. February 1, 2026.

12 NCAC 09I .0102 COURSE MANAGEMENT FORMS

The following Commission-approved forms shall be used by certified School Directors during the administration of Commission-approved courses:

(1) Form F-10A, Pre-Delivery Report of Training Course Presentation, shall include the following:

(a) Name of delivery site (academy);

(b) Proposed Commission course being requested to administer;

(d) Location of course delivery;

(e) Commencement and completion dates;

(f) Anticipated class size;

(g) Names of all delivery site (academy) staff requiring administrative access to the course page on the North Carolina Justice Training and Certification Portal; and

(h) Name and signature of certified School Director.

(2) Form F-10B and Web Form F-10B, Post Delivery Report of Training Course Presentation, shall include the following:

(a) Name of delivery site (academy);

(b) Commission course administered;

(d) Location of course delivery;

(e) Commencement and completion dates;

(f) Final class size; and

(g) Name and signature of certified School Director.

(3) Form F-23, Commission Exam Admission Form, shall include the following:

(a) Course pre-delivery number, exam location, and exam date;

(b) First-Time Exam Admission information;

(d) Name and signature of certified School Director; and

(e) List of all trainees.

(4) Web Form WF-6, CJ Standards Specialized Training Departure Report, shall include the following:

(a) Course name, course dates, and training location;

(b) Departing student's name, date of birth, and academy ID number; and

History Note: Authority G.S. 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0103 BASIC LAW ENFORCEMENT TRAINING (BLET) COURSE FORMS

The following Commission-approved forms shall be used by certified School Directors and instructors during the administration of a Commission-approved Basic Law Enforcement Training (BLET) course:

(1) Form F-13, Request for Deficiency Remediation, shall include the following:

(a) Name of certified School Director and delivery site (academy);

(b) Date of request and state exam date;

(d) Block of instruction and dates of deficiency;

(e) Instructor's name and academy ID number;

(f) Remediation location and dates of remediation;

(g) Details of remediation plan; and

(h) Signature of certified School Director.

(2) Form F-14, Request for Limited Enrollment, shall include the following:

(a) Name of certified School Director and delivery site (academy);

(b) Date of request and original BLET start date;

(d) Blocks of instruction for make-up training; and

(e) Delivery site (academy) where make-up training will be conducted.

(3) Form F-17, Student Evaluation of Instructors, shall include the following:

(a) Name of delivery site (academy);

(b) Instructor's name;

(d) Evaluation of delivery of course material by instructor; and

(e) Evaluation of organization and presentation of delivery of instruction;

(4) Form F-25, Criminal Record Conviction History for BLET, shall include the following:

(a) Agency name and address;

(b) Applicant's full name and former names;

(d) Name and signature of Agency head.

(5) Form F-26, BLET Student Absence Report, shall include the following:

(a) School or academy name and class name;

(b) Student's name and academy ID number;

(d) Hours missed and made up;

(e) Reason for missed time;

(f) Student's and certified School Director's signature and date; and

(g) Name of instructor conducting the make-up training.

(6) Form F-32, BLET Request for Early Enrollment, shall include the following:

(a) Name and signature of certified School Director and delivery site (academy);

(b) Student's name and date of birth; and

(7) Web Form WF-1, BLET Student Injury Report, shall include the following:

(a) Student's name, date of birth, and academy ID number;

(b) Date and details of injury;

(d) Email address of School Director.

(8) Web Form WF-2, BLET Departure Report, shall include the following:

(a) Student's name and academy ID number;

(b) Date, reason, and details of departure; and

(9) Web Form WF-3, BLET Student Enrollment Questionnaire, shall include the following:

(a) Student's demographic information, including gender and employment status;

(b) Student's education information, including highest education level, name of institution, and degree earned;

(d) Student's primary language.

(10) Web Form WF-4, BLET Student Course Completion Record, shall include the following:

(a) Student's name and academy ID number;

(b) Student's gender;

(d) Student's hiring status with a law enforcement agency; and

(e) Course completion information, including whether the student completed all course requirements and passed the state exam.

(11) Web Form WF-13B, BLET Deficiency, Report of Completed Training, shall include the following:

(a) Student's name and academy ID number;

(b) Deficiency information, including the number and names of instructional topics which the student is deficient in;

(c) Deficiency make-up information, including whether the student completed all required coursework for the instructional topic in which he or she is remediating and whether the remediation occurred outside of the scheduled course hours;

(d) Date the deficiency remediation was completed; and

(e) School Director's name, signature, and email address.

History Note: Authority G.S. 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0104 COMMISSION-ACCREDITED DELIVERY SITE ADMINISTRATION FORMS

The following Commission-approved forms shall be used by Commission-accredited delivery sites to administer Commission-approved courses:

(1) Form F-10, School Director/Qualified Assistant Application, shall include the following:

(a) the name of the appointing institution or agency;

(b) the applicant's name, date of birth, last four digits of social security number, phone number, email address, instructor certification number, and the location and date the applicant completed orientation training;

(c) the applicant's educational background, specifically, the dates of attendance, the institution attended, and the degree or diploma attained from each institution;

(d) the applicant's criminal justice experience, specifically, the agency for which the applicant worked, the applicant's duties in each position, and the dates of employment. The applicant shall have acquired four years of practical experience as a criminal justice officer or as an administrator or specialist in a field directly related to the criminal justice system. At least one year of the required four years of experience must have been completed while actively participating in criminal justice training as a Commission-certified instructor;

(e) the signature of the applicant certifying the accuracy of the contents of the application; and

(f) the signature of the appointing institution's executive officer signifying recommendation of an applicant to be a School Director; or

(g) the signature of the School Director signifying recommendation of an applicant to be a Qualified Assistant.

(2) Form F-10 (SA), Accreditation of Criminal Justice Schools, shall include the following:

(a) the name of the requesting institution or agency;

(b) the mailing address, phone number, and name of the institution head or executive officer;

(d) the type of Commission-approved training course in which accreditation is being sought;

(e) the type and location of all facilities to be used in administering the Commission-approved training course; and

(f) the signature of the institution head or executive officer.

History Note: Authority G.S. 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0105 MEDICAL FORMS

The following Commission-approved forms shall be used by agencies and Commission-accredited delivery sites during the application for criminal justice certification or Commission-approved training course enrollment:

(1) Form F-1, Medical History Statement, shall include the following:

(a) Applicant's name, date of birth, address, and telephone number;

(b) Current medications, allergies, and past medical history;

(d) Applicant's signature; and

(e) Name and signature of a physician, physician assistant, or nurse practitioner who holds a current license in the United States to practice medicine, as issued by a state medical board.

(2) Form F-2, Medical Examination Report, shall include the following:

(a) Name, date of birth, employing agency, height, weight, and last four digits of the Social Security Number for the person being examined;

(b) Results of Vision Acuity;

(d) Results of Cardiovascular Examination;

(e) Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and

(f) Name, signature, and medical license number of the examining medical professional.

(3) Form F-2A, Tuberculosis Questionnaire, shall include the following:

(a) Applicant's name, date of birth, and employing agency;

(b) Tuberculosis Risk Questions and individual's response; and

(4) Form F-2B, Medical Examination Report Addendum, shall include the following;

(a) Name, date of birth, and employing agency of individual being examined;

(b) Additional Exam Notes, if any;

(c) Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and

(d) Name, signature, and medical license number of examining medical professional.

(5) Form F-31, Request for Accommodation, shall include the following:

(a) Name, signature, and date of birth of requesting student;

(b) Accredited delivery site, and name of certified School Director;

(d) Proposed Accommodation.

(6) Web Form WF-5, CJ Standards Specialized Training Student Injury Report for SMI, Instructor Courses, shall include the following:

(a) Course name, course dates, and training location;

(b) Injured student's name, date of birth, and academy ID number;

(d) Details of the injury, including what the injury is, when and where it took place, and how the injury occurred;

(e) Whether the student was able to return to training on the same day as the injury occurred; and

(f) Whether the student was transported to a hospital or other medical facility for assessment or treatment of the injury.

History Note: Authority G.S 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0106 SPEED-MEASURING INSTRUMENT (SMI) FORMS

(a) The following Commission-approved forms shall be used by certified SMI instructors during the administration of SMI courses:

(1) Form SMI-1, Moving/Stationary Radar Motor Skill Performance Test, shall include the following:

(A) Trainee's full name, employing law enforcement agency, date of birth, academy ID number, email address, and phone number;

(B) Radar instrument being tested on and name of the instrument's manufacturer;

(D) Verification by the evaluating instructor that the trainee completed each step of the instrument sign-off, evidenced by the instructor's initials;

(E) Timing and results of the trainee's motor skills testing; and

(F) Name, academy ID number, and signature of each evaluating instructor verifying whether the trainee successfully completed the motor skill performance test.

(2) Form SMI-1A, Moving/Stationary Radar Instrument Sign-Off, shall include the following:

(A) Trainee's full name, employing law enforcement agency, date of birth, academy ID number, email address, and phone number;

(B) Radar instrument being tested on and the name of the instrument's manufacturer;

(D) Verification by the evaluating instructor that the trainee completed each step of the instrument sign-off, evidenced by the instructor's initials; and

(E) Name, academy ID number, and signature of each evaluating instructor verifying whether the trainee successfully completed the motor skill performance test.

(3) Form SMI-13, Lidar Motor Skill Performance Test, shall include the following:

(A) Trainee's full name, employing law enforcement agency, date of birth, academy ID number, email address, and phone number;

(B) Lidar instrument being tested on and name of the instrument's manufacturer;

(C) Verification by the evaluating instructor that the trainee completed each step of the instrument sign-off, evidenced by the instructor's initials; and

(D) Name, academy ID number, and signature of each evaluating instructor verifying whether the trainee successfully completed the motor skill performance test.

(4) Form SMI-16, Written Endorsement to Attend Supplemental SMI Training, shall include the following:

(A) Name, academy ID number, date of birth, email address, and employing law enforcement agency of each trainee enrolled in the course;

(B) List of speed measuring instruments each trainee is currently certified to operate;

(D) Name, academy ID number, and signature of each instructor of the course; and

(E) Name, employing agency, title, email address, phone number, and signature of School Director, agency head, agency head designee, or in-service training coordinator.

(b) The following Commission-approved forms shall be used by individuals applying for certification as a Radar operator:

(1) Form SMI-14, Trainee's Statement of Prior Radar Training, shall be filled out by a trainee enrolled in a radar or radar/lidar operator training course, as prescribed by 12 NCAC 09B .0212(a) and .0242(a), who has previously been certified by the Commission as a radar operator. The trainee shall sign and date the form prior to submission. The form shall also include the following:

(A) Trainee's full name, academy ID number, date of birth, and employing law enforcement agency;

(B) Name of the institution or agency at which the trainee received prior training;

(D) End date and total hours of prior radar training.

(2) Form SMI-15, SMI Operator Supervised Field Instruction/Practice Log, shall be completed by a trainee completing Supervised Field Practice within the 90 days following the completion of a SMI operator course, pursuant to 12 NCAC 09B .0409(a)(4) and (c). The form shall include the following:

(A) Trainee's full name, employing law enforcement agency, academy ID number, email address, and phone number;

(B) Dates and times of supervised field practice;

(D) Location and end date of the trainee's SMI operator course;

(E) Name and modes of instrument used during the supervised field practice;

(F) Total time of supervised field practice; and

(G) Trainee's signature and date of form completion.

(1) Form SMI-9, Record of Radar Instrument Calibration and Accuracy Tests, shall include the following:

(A) Agency or organization name;

(B) Instrument model, manufacturer, serial number, modes, and features;

(D) Name, license or certification information, and signature of the testing technician verifying that the instrument passed the tests.

(2) Form SMI-12, Record of Lidar Instrument Calibration and Accuracy Tests, shall include the following:

(A) Agency or organization name;

(B) Instrument model, manufacturer, serial number, modes, and features;

(D) Name, license or certification information, and signature of the testing technician verifying that the instrument passed the tests.

History Note: Authority G.S. 8-50.2; 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0107 PROFESSIONAL CERTIFICATES FORMS

The following Commission-approved forms shall be used by individuals to apply for a new or replacement Professional Certificate:

(1) Form F-6 (LE), Application for Award of Law Enforcement Certificate, shall include the following:

(a) Applicant's name, date of birth, and last four digits of Social Security Number;

(b) Applicant's address, phone number, and email address;

(d) Type of award applying for;

(e) Law enforcement experience (agencies and years of law enforcement experience);

(f) Completed law enforcement training courses;

(g) Level of college education;

(h) Name and signature of applicant; and

(i) Name and signature of agency head or In-Service Training Coordinator.

(2) Form F-6 (DAC), Application for Award of Criminal Justice Certificate, shall include the following:

(a) Applicant's name, date of birth, and last four digits of Social Security Number;

(b) Applicant's address, phone number, and email address;

(d) Type of award applying for;

(e) Criminal justice experience (agencies and years of criminal justice experience);

(f) Completed criminal justice training courses;

(g) Level of college education;

(h) Name and signature of applicant; and

(i) Name and signature of agency head or In-Service Training Coordinator.

(3) Form F-6 (DJJ), Application for Award of Juvenile Justice Certificate, shall include the following:

(a) Applicant's name, date of birth, and last four digits of Social Security Number;

(b) Applicant's address, phone number, and email address;

(d) Type of award applying for;

(e) Juvenile justice experience (agencies and years of juvenile justice experience);

(f) Completed juvenile justice training courses;

(g) Level of college education;

(h) Name and signature of applicant; and

(i) Name and signature of agency head or In-Service Training Coordinator.

(4) Form F-7, Request for Replacement of Professional Certificate, shall include the following:

(a) Awardee's name, date of birth, and last four digits of Social Security Number;

(b) Awardee's address, phone number, and email address;

(d) Printed name and signature of awardee; and

(e) Name and signature of agency head or In-Service Training Coordinator, if still employed at an agency.

History Note: Authority G.S. 17C-6;

Eff. February 1, 2026.

12 NCAC 09I .0108 BASIC TRAINING FORMS – JUVENILE JUSTICE AND ADULT CORRECTION

The following Commission-approved forms shall be used by agencies and Commission-accredited schools, pursuant to 12 NCAC 09C .0401 and 12 NCAC 09G .0402, for officers holding probationary certification, pursuant to 12 NCAC 09C .0303 and 12 NCAC 09G .0303:

(1) Form F-11, Report of Training Course Completion, shall include the following:

(a) student's name, academy ID number, and date of birth;

(b) name of employing agency;

(d) course title, location, start date, end date, meeting times, and total hours;

(e) whether the student passed the course; and

(f) name of individual completing the form and date of form completion.

(2) Form F-15, Request for Training Extension, shall include the following:

(a) date of request;

(b) employee's name, date of birth, last four of social security number, and position title;

(d) scheduled basic training course type and course start and end dates;

(e) reason for employee not completing basic training;

(f) proposed start and end dates for subsequent basic training;

(g) employee's name, signature, and date signed;

(h) school director's name, signature, and date signed; and

(i) agency authorized representative's name, signature, and date signed.

History Note: Authority G.S. 17C-6;

Eff. October 1, 2026.

12 NCAC 09I .0109 CERTIFICATION FORMS – ADULT CORRECTION

The following Commission-approved forms shall be used during the application process for correctional officer or probation/parole officer certification:

(1) Form F-5A (DAC), Adult Correction Report of Appointment and Application, shall include the following information about the applicant:

(a) type of certification applying for;

(b) name, social security number, previous names used, date of birth, home address, phone number, driver's license number and issuing state, and email address;

(c) prior certification history, including whether the applicant previously held a position requiring certification or licensure from any commission, board, or agency and whether any previous certification was suspended or revoked;

(d) whether the applicant has ever been denied employment for a position with a law enforcement agency, corrections agency, or security agency;

(e) names and types of relationships with any family member in prison, jail, or on probation or parole;

(f) history of illegal drug use;

(g) criminal history information, including offense, type of offense, disposition offense, date of offense and disposition, court docket number, county and state, and probation status for all offenses charged, expunged, and pending;

(h) explanation of any Domestic Violence Orders, Ex-Parte Domestic Violence Protection Orders, or any other protective orders issued against the applicant;

(i) military history, including date and type of last discharge, and the branch, type of discharge, and start and end dates of service for all periods of active duty;

(j) explanation for any type of military discharge other than honorable;

(k) report of appointment information to be completed by the agency authorized representative, including: applicant's position title, Beacon number, effective date, education and degree information, date of fingerprinting, date Division of Criminal Information Network (DCIN) checks completed, date psychology screening conducted, name and license number of psychologist, date of negative drug test and name of lab, whether Forms F-1 and F-2 were completed (pursuant to .0105 of this Subchapter), date of physical exam, name and license number of examining medical practitioner;

(l) notarized signature of the applicant; and

(m) signature of agency authorized representative.

(2) Form F-5C (DAC), Report of Reappointment/Reinstatement of Certification, shall include the following information about the applicant:

(a) type of certification applying for;

(b) type of application (transfer from a non-certified position or reappointment following separation);

(c) name, social security number, previous names used, date of birth, home address, phone number, driver's license number and issuing state, and email address;

(d) criminal history information, including offense, type of offense, disposition offense, date of offense and disposition, court docket number, county and state, and probation status for all offenses charged, expunged, and pending;

(e) explanation of any Domestic Violence Orders, Ex-Parte Domestic Violence Protection Orders, or any other protective orders issued against the applicant;

(f) report of appointment information to be completed by the agency authorized representative, including: position title and effective date, Beacon number, date of fingerprinting, date DCIN checks completed, date psychology screening conducted, name and license number of psychologist, date of negative drug test and name of lab;

(g) notarized signature of the applicant; and

(h) signature of agency authorized representative.

(3) Form F-5D (DAC), Notice of Certification Transfer, shall include the following information about the applicant:

(a) name, Beacon number, social security number, date of birth, email address, home address, and phone number;

(b) current or previous certification type and certification type transferring to;

(d) education and experience information;

(e) notarized signature of the applicant; and

(f) signature of the agency authorized representative.

(4) Form F-5E (DAC), Notice of Transfer to a Non-Certified Position, shall include the following information about the transferring officer:

(a) name, date of birth, and last four of social security number;

(b) original certification date;

(d) title of non-certified position;

(e) type of last certification held, including whether it was probationary or general and whether it was correctional officer certification or probation/parole officer certification;

(f) whether basic training was completed;

(g) whether the officer has been subject to a disciplinary transfer;

(h) name, title, and signature of agency head or authorized representative;

(5) Form F-38 (DAC), Authorization for Release of Information to North Carolina Criminal Justice Education and Training Standards Commission and North Carolina Department of Adult Correction, shall include the following:

(a) applicant's name, date of birth, driver's license number and issuing state, home address, and phone number; and

(b) applicant's notarized signature.

History Note: Authority G.S. 8-50.2; 17C-6;

Eff. October 1, 2026.

12 NCAC 09I .0110 Certification Forms – Juvenile Justice

The following are Commission-approved forms to be used by individuals certified as, or applicants for certification as, juvenile justice officers or juvenile court counselors:

(1) Form F-5A (JJ), Application for Certification - Juvenile Justice Officer & Juvenile Court Counselor, shall include the following:

(a) name, phone number, and address of employing agency;

(b) applicant's name, previous names used, social security number, home address, date of birth, driver's license number and issuing state, email address, and phone number;

(d) position title and full-time or part-time status;

(e) verification that the applicant has completed certification requirements as set out in 12 NCAC 09B .0116 or .0117, including:

(i) education information, including highest level of education, name and location of high school, type of higher education degree earned, name and location of higher education institution, and how each type of education and/or degree was verified by the employing agency;

(ii) drug screening date, result, and name of laboratory;

(iii) date submitted fingerprints to State Bureau of Investigation and results shall be attached;

(iv) psychological screening date and the name and license number of the evaluating psychologist or psychiatrist;

(v) indication that medical forms, pursuant to .0105 of this Subchapter, have been completed, date of medical examination, and name and license number of examining medical professional;

(vi) indication that background investigation and associated forms, pursuant to 12 NCAC 09B .0102, have been completed;

(vii) indication of whether the applicant has prior military experience and attached military records if applicable;

(viii) employment history of the applicant, supported by Form F-8, pursuant to 12 NCAC 09B .0102, if applicable;

(ix) attached a completed Form F-36, pursuant to 12 NCAC 09I .0116; and

(x) applicant's arrest, criminal, probation, and Domestic Violence Protective Order history, supported by Form F-3, pursuant to 12 NCAC 09B .0102, if applicable;

(f) date completed Application for Verification of Expungement AOC-CR-280;

(g) signature of applicant and date signed; and

(h) name, title, and signature of executive officer or authorized representative of the employing agency and date signed.

(2) Form F-5D (JJ), Application for Change in Juvenile Justice Certification, shall include the following:

(a) facility or district of employment;

(b) applicant name, academy ID number, social security number, date of birth, email address, home address, and phone number;

(d) type of certification transferring to;

(e) effective date of transfer;

(f) full-time or part-time status;

(g) education information, including how the applicant's high school education was verified by the employing agency, how the applicant's college education was verified; type of college degree earned; and institution name;

(h) notarized signature of the applicant; and

(i) name, title, and signature of executive officer or authorized representative of the employing agency and date signed.

(3) Form F-19 (JJ), Notification of Personnel Record Change, shall include the following:

(a) employing agency name;

(b) individual's name on file with the Division, academy ID number, date of birth, and social security number;

(i) new full name;

(ii) reason for name change; and

(iii) attached documentation, if applicable.

(d) for those notifying of a status change:

(i) current full-time or part-time status; and

(ii) status changing to;

(e) name, title, and signature of agency head and date signed.

History Note: Authority G.S. 17C‑6;

Eff. October 1, 2026.