B-4.2.2 Youth Consultation Service

SHIFT SUPERVISOR

Supervision Form

Employee Name: ______

Job Title: ______

Period covered by report: From: ______To:______

Instructions: Listed below are examples of topics to review/discuss under each section of the blank Supervision Form for the Site Administrator supervising the Shift Supervisor role. The supervisor is to check all topics discussed on the blank line next to each topic area and note additional topics and comments below. There should be a comment noted when improvement in performance has occurred or when improvement is needed. Both the supervisor and employee are to sign this form which indicates topics checked and comments noted were reviewed and/or discussed.

_____ Accomplishments (e.g. results produced, outcomes, effectiveness of projects and/or responsibilities, etc.)

:

(a)Maintains frequent communication with all RA’s.

(b)Arrives to shift 10 min early to review unit logs, alerts, scheduled appointments and special instructions. Hands off communication with incoming shift supervisor at the end of the shift.

(c)Oversees staff to be sure that they are reading, initialing and neatly and legibly documenting communication binders and logbooks and that all are up-to-date.

(d)Reviews log books and incident reports competed by RAs to ensure that they correspond to one another, time and information need to match.

(e)Orientation of new hires.

(f)Ensures restraint protocols/procedures are adhered to.

(g)Performs 90 day review.

(h)Other topic(s). ______Comment(s)

______

_____ Challenges/Needs (e.g. individual, program, staff, emotional, workplace pressures, etc.)

(a)Addresses parent issues/concerns appropriately and effectively.

(b)Makes sure RAs keep clients in proper eye-sight and knows where Clients are at all times.

(c)Ensures proper staffing levels and reduces overtime.

(d)Makes sure all physical controls are justified and done safely, without injury to client or staff, with documentation and defriefing.

(e)Supervises staff, addresses and works to resolve staff issues effectively.

(f)Other topic(s). ______

Comment(s)

______

_____ Goals/Plans/Program Development/Suggestions

(a)Aware of each client’s treatment goals and works to ensure goals are met.

(b)Fosters a therapeutic environment of care.

Other topic(s). ______Comment(s)

______

_____ Professional Development (e.g. education and training, career planning, etc.)

(a)Leads and participates in client activities.

(b)Supervise and evaluate work performance of Child Care/RA staff regularly.

(c)Maintains own CPI, CPR, Handle with Care [HWC], First Aid, YCS Medication Administration Certification (if applicable).

(d)Assist and support staff’s professional development, gives acknowledgement for job well done and constructive feedback.

(e)Other topic(s). ______

Comment(s)

______

Supervisor Name (print): ______

Supervisor Signature: ______Date: ______

Employee Name (print): ______

Employee Signature: ______Date: ______

Research-HR\EMPLOYEE SATISFACTION\COMBINED TEAM\Shift Supervisor Supervision Form.doc11/25/09

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