A 5-page Word checklist for a supervisor to observe a caregiver’s hands-on skills and record results and retraining.

For USA non-medical home care agency owners, supervisors, and trainers. Plus 1 agency instructions page to remove before use.

What’s included

1. Page 1: employee, evaluation type and date, evaluator, and Section A infection control
2. Page 2: Section B safety, mobility, and emergency response
3. Page 3: Section C personal care assistance, nutrition, and medication reminders
4. Page 4: Section D client rights, communication, reporting, and documentation, and Section E additional state or agency skills
5. Page 5: results summary, remediation plan with re-evaluation dates, evaluator qualifications, and signatures
6. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. This checklist records observed skills; it does not certify anyone or replace state-required training. Use an evaluator who meets your state rules.