QPC & PSS Supervision Agenda Tracking

Qualified Peer Coordinator (QPC) Name *

First Name

Last Name

Registered Site Address *

Indicate the Site Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

QPC Phone *

(###)

###

####

Peer Support Specialist (PSS) Name *

Indicate the name of the PSS with whom Supervision was held.

First Name

Last Name

Date that QPC & PSS Supervision was held. *

Indicate the date that the supervision was held.

MM

DD

YYYY

What Agenda items were discussed on the date of this supervision? *

Indicate the Supervision topics that were covered.

Agenda topic #1 - PSS Well-Being and Support

Agenda topic #2 - PSS Skills, Training and Development

Agenda topic #3 - PSS Activity Documentation and FELT-Impact Review

Emergency supervision

Other agenda topic

PSS-WBSRS – Physical Well-Being *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Cognitive Well-Being *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Emotional Well-Being *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Spiritual Well-Being *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Work Satisfaction *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Recreation Satisfaction *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – Relational Satisfaction *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10

PSS-WBSRS – General Well-Being *

This scale is intended to reflect current (within the past 24 hours) well-being and satisfaction. Lower numbers indicate less well-being and/or satisfaction while higher numbers indicate greater well-being and/or satisfaction.

1

2

3

4

5

6

7

8

9

10