• Care home

  • Conducted on

  • Location

Staff Details

  • Name of Supervisee:

  • Job Title:

  • This form must be completed when there is a cause of concern.

Work Based Supervision

  • Accurately describe the concern you have with the staff member.

  • What is the impact of the concern.

  • Staff members response.

  • What actions has the staff member put in place to prevent the above from happening?

  • Does the staff member have any concerns or issues they wish to discuss? If YES, please describe.


  • Training organised?

  • Recommended training

Other Relevant Information

  • Discuss areas for improvement for the staff member. i.e. Look at areas where the staff member can improve their work and stay motivated etc.

  • Date for next supervision

  • Location of next supervision

  • Supervisee Signature

  • Supervisor Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.