Home / Forms / Appendix V

Staff Supervision Record

Document supervision sessions, feedback, and follow-up.

Kura Solution

Appendix V — Staff Supervision Record

Document supervision sessions, feedback, and follow-up.

Staff Name *

Supervisor Name *

Date of Supervision *

Duration (minutes)

Topics Discussed

Performance Feedback

Training / Support Needs

Next Supervision Date

Supervisor Signature

Supervisor Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Supervisor Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.