New Hire Package - Revised Employee Qualifications, Requirements, And Forms Page 29

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SKILLS COMPETENCY CHECKLIST FOR SERVICE PROVIDERS
Date
Date
Competency
Initials
Initials
Trained
Observed
Skill / Instructions
Trainer
Trainee
________
________
Work Schedule
_______
_______
________
________
Reviewed care plan & person centered planning
and/or goals
_______
_______
________
________
Meal Preparation and/or feeding
_______
_______
________
________
Household tasks (laundry, cleaning, etc.)
_______
_______
________
________
Grocery Shopping
_______
_______
________
________
Bathing
_______
_______
________
________
Toileting
_______
_______
________
________
Personal Hygiene
_______
_______
grooming  hair care 
skin care  oral care 
shaving
________
________
Transfers and Ambulation
_______
_______
________
________
Bed mobility / positioning
_______
_______
________
________
Dressing
_______
_______
Mobility around  home  community
________
________
_______
_______
________
________
Exercise
_______
_______
________
________
Medication assistance
_______
_______
________
________
Escort_______________________________
_______
_______
________
________
Supervision/Stand-by assistance
_______
_______
Oral care
________
________
Habilitation Training
_______
_______
 Money management Self care
 Community Integration
 Socialization Personal decision making
Training on use of adaptive aids
Cueing and/or standby assistance
________
________
Other_______________________________
_______
_______
________
________
Other_______________________________
_______
_______
________
________
Other_______________________________
_______
_______
________
________
Other_______________________________
_______
_______
Page 29--6/11/15

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