Home Visitor'S Doctor Supervision Log Template
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1Supervision Log
HFA Goal: 90% of required weekly individual supervisory sessions for direct service staff occur weekly and are held
for a minimum of 1.5 – 2 hours for .75-1 FTE and .25-.74 FTE a minimum of 1 hour. Calculate percentages each
quarter out of eligible number of weeks.
Home Visitor Name: ________________________________
Date
Time
Comments (reasons for missing/
cancelling/rescheduling)
# of supervisory sessions this past
# meeting the required time frame
Comments:
quarter _____/______ = _____%
______/______ = _____%
Date
Time
Comments (reasons for
missing/cancelling/rescheduling)
# of supervisory sessions this past
# meeting the required time frame
Comments:
quarter _____/_____ = _____%
______/______ = _____%
Supervisor Name: ___________________________________
017-0_SR_SupervisionLog
Rev. 5/2014
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