APPLICABLE INFORMATION

ANSWER THE QUESTIONS BELOW PERTAINING TO THE MENTOR

DOES THE MENTOR HAVE THE DESIRE, A PATIENT DISPOSITION, AND IS WILLING TO DEVOTE THE NECESSARY TIME TO SUCCEED AS A MENTOR?

DOES THE MENTOR POSSESS THE KNOWLEDGE AND SKILLS IN THE TASK BEING PERFORMED BY THE SSE

WILL THE MENTOR BE AVAILABLE TO PERFORM A MINIMUM OF FOUR OBSERVATIONS ON THE DESIGNATED SSE EVERY MONTH?

WILL THE MENTOR'S SUPERVISOR REVIEW PROGRESS ON A ONTHLY BASIS WITH SSE AND MENTOR?

DOES THE MENTOR AGREE TO COACH, EDUCATE, AND TRAIN THE SSE THE PROPER WAY TO APPLY BEHAVIORAL SAFETY PROCESS?

MENTOR SIGNATURE
SUPERVISOR SIGNATURE
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.