Qualified Professionals’ PCA Supervision Checklist

Student: Paraprofessional: Date of Birth: Supervisor: School: Date:

Training 120 day evaluation 14 day evaluation Other: 90 day evaluation

1. The care plan was reviewed with the paraprofessional and needed services are understood? Yes No If No, then describe concerns and actions taken:

2. The paraprofessional is capable of providing services as outlined in the care plan? Yes No If No, then describe concerns and actions taken:

3. The paraprofessional is able to identify conditions that should be immediately brought to the case manager and supervisor’s attention? Yes No If No, then describe concerns and actions taken:

4. The paraprofessional is adequately documenting the services provided? Yes No If No, then describe concerns and actions taken:

5. The paraprofessional services are meeting the goals of the care plan? Yes No If No, then describe concerns and actions taken:

6. The care plan was revised based on consultation with the case manager and paraprofessional? Yes No

______Supervisor’s Signature Date

3rdParty/2010-2011/QP Supervision October 2010