State Referee Practical Exam

USA Powerlifting Referee Practical Exam Results

Proctor, please fill out the information below.
Instructions: For state and national level referee exams, this form is to be completed and submitted by the state chair or the examiner who administered the practical exam. For category 2 and 1 exams, this form is to be completed and submitted by the technical secretary of the event or a member of the USA Powerlifting Technical Committee. For the purposes of this form, “examiner” is the referee who administered the practical exam, and “candidate” is the person who took the exam and was being tested. If more than one person served as the examiner (e.g., referee A examined the squat portion and referee B examined the bench press and deadlift portions), the details of who examined which portions should be provided in the “Comments” section at the bottom of this form. Only one examiner needs to be identified in the “Name of Examiner” field below. For category 1 exams, there is a place below where the names of all three examiners on the jury are to be listed.
Name of person completing this form*

First NameLast Name
Email of person completing this form*

Confirmation Emailexample@example.com
Role of person completing this form*
Examiner’s Name*

First NameLast Name
Examiner’s Referee Rank*
Date of Practical Exam*

MonthDayYear
Date
USA Powerlifting Event Name*
USA Powerlifting Event Sanction Number*
Level of Event*
Was the practical exam conducted in the United States?*

YesNo
If the practical exam was not conducted in the United States, select the country in which the exam occurred
Candidate’s Name*

First NameLast Name
Candidate’s State
Candidate’s Email*

Confirmation Email
Candidate’s Membership Number*
Candidate’s Membership Current?*

YesNo
Did the candidate pass the written exam prior to taking the practical exam?
If no, please provide an explanation in the “Comments” section at the bottom of this form..
Number of Squats Missed*
Number of Bench Presses Missed*
Number of Deadlifts Missed*
Total Missed
Level of Referee Exam*
Was equipment check observed
Was weigh-in observed
Was drug testing protocol observed
If the candidate did not observe equipment check, weigh-in, and the drug testing protocol, please explain why in the “Comments” section at the bottom of this form.
Management of weigh-in
Name of technical secretary who observed candidate managing weigh-in

First NameLast Name
Supervision of equipment check and weigh-in
Name of technical secretary who observed candidate supervising equipment check and weigh-in

First NameLast Name
Names of three jury members who served as practical examiners

First NameLast Name
First NameLast Name
First NameLast Name
Pick your State Chair email.*
Comments?
Signature of person completing and submitting this form*

Clear
Should be Empty:

USA Powerlifting Referee Practical Exam Results