Caregiver Spot Check Assessment
Complete this form to assess caregiver performance during an unannounced spot check visit.
Caregiver Full Name
*
First Name
Last Name
Client Full Name
*
First Name
Last Name
Date and Time of Spot Check
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Was the caregiver on time?
*
Yes
No
Not Applicable
Caregiver Appearance and Professionalism
*
1
2
3
4
5
Care Plan Adherence and Task Completion
*
Rows
Completed
Partially Completed
Not Completed
Not Applicable
Personal hygiene tasks
1
2
3
4
Meal preparation
5
6
7
8
Medication reminders
9
10
11
12
Mobility/Transfers
13
14
15
16
Light housekeeping
17
18
19
20
Communication and Interpersonal Skills
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Did the caregiver follow safety protocols?
*
Yes
No
Not Observed
Overall Performance Rating
*
1
2
3
4
5
Additional Comments or Observations
Assessor Full Name
*
First Name
Last Name
Signature of Assessor
*
Submit Assessment
Submit Assessment
Should be Empty: