Employee Supervision Form
Employee Name
First Name
Last Name
Supervisor Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Supervision Period
Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Performance
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
N/A
Quality Assurance(Ensuring referrals are contacted, team leads reviewing notes, etc.)
1
2
3
4
5
Entering case notes
6
7
8
9
10
Responsiveness
11
12
13
14
15
Time Management
16
17
18
19
20
Effective Billing Practices
21
22
23
24
25
Pro-activeness
26
27
28
29
30
Do you have any concerns at work?
Employee Success Story
Manager suggestions for growth
Employee suggestions for growth
Course of action
Are you accessing independent supervision?
Would you like more or less feedback on your work? If so, what additional feedback would you like?
Are there any decisions you really need assistance with?
Where do you see yourself this time next year?
Number of participants you are working with
Salary Increase? Please state the reason for your answer.
Employee Signature - I agree this record is a true reflection of our discussion
*
Supervisor Signature - I agree this record is a true reflection of our discussion
*
Submit
Should be Empty: