<p> Qualified Professionals’ PCA Supervision Checklist</p><p>Student: Paraprofessional: Date of Birth: Supervisor: School: Date: </p><p>Training 120 day evaluation 14 day evaluation Other: 90 day evaluation</p><p>1. The care plan was reviewed with the paraprofessional and needed services are understood? Yes No If No, then describe concerns and actions taken:</p><p>2. The paraprofessional is capable of providing services as outlined in the care plan? Yes No If No, then describe concerns and actions taken:</p><p>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:</p><p>4. The paraprofessional is adequately documenting the services provided? Yes No If No, then describe concerns and actions taken:</p><p>5. The paraprofessional services are meeting the goals of the care plan? Yes No If No, then describe concerns and actions taken:</p><p>6. The care plan was revised based on consultation with the case manager and paraprofessional? Yes No</p><p>______Supervisor’s Signature Date</p><p>3rdParty/2010-2011/QP Supervision October 2010</p>