Sample download
Supervisor sign-off checklist (sample)
A printable example of the checklist that ships with every TPM module. Fictional content, clearly labeled.
SAMPLE · Fictional content for illustration only · Not clinical guidance · Not a real learner or organization
Supervisor Competency Sign-off
Module: Fall Prevention Rounding: Home Visits · v1.0 · Policy SAMPLE-CL-031
Sample Home Health Agency
(fictional)
Prepared with TPM Interactive Learning Studio
(fictional)
Prepared with TPM Interactive Learning Studio
Learner name
Role
Module completed (date)
Module score
Observation setting Patient visit Simulation
Date observed
Instructions: Observe the learner during a real or simulated visit. Mark each behavior Met, Not met, or N/A, and comment on any “Not met.” Re-observe any “Not met” item within 14 days.
| # | Observable behavior | Met | Not met | N/A | Comments |
|---|---|---|---|---|---|
| 1 | Completes the five-point living-path scan: lighting, floors and rugs, cords and clutter, footwear, bathroom access (3.1) | ||||
| 2 | Places the assistive device within reach and confirms it is used as instructed (3.2) | ||||
| 3 | Asks about falls, near-falls, and new dizziness since the last visit (3.3) | ||||
| 4 | Reports a fall, near-fall, dizziness, or unresolved hazard to the RN case manager the same day (3.4) | ||||
| 5 | Teaches one hazard correction and documents the scan, teaching, and any report (3.5) |
Overall: Competent Re-observation needed by ____/____/______
Observer name, credentials, and signature
Learner signature
This checklist supports your organization’s documentation of training. It doesn’t by itself certify regulatory compliance. On-the-job observation is performed by your qualified staff under your policies.
Next step
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