Staff Orientation & Training Checklist
Staff Name ______________________________________________________________________________
Date of Hire/First Day of Work _____/_____/_____
Date Background Study Initiated _____/_____/_____
Date Background Study Notice Received _____/_____/_____
Date of First Supervised Direct Contact with Participants _____/_____/_____
Date of First Unsupervised Direct Contact with Participants _____/_____/_____
Orientation Requirements - This program ensures competency in the following areas as required in the 245D HCBS Standards, section 245D.09. 10 hours of orientation must be completed within 60 days of hire for support workers that combines supervised on-the-job training with review of and instruction in the following areas:
|Training Subject |Date of Training |Trainer/Initials |
|Within 3 Days | |Program Director |
| | | |
|Application/Information Sheet |____/____/____ |__________________________ |
|Personnel Action Form |____/____/____ |__________________________ |
|Job Description/Job Functions |____/____/____ |__________________________ |
|Education/Credentials/Licenses |____/____/____ |__________________________ |
|I-9 |____/____/____ |__________________________ |
|W-4 |____/____/____ |__________________________ |
|Direct Deposit Form |____/____/____ |__________________________ |
|Driver’s License/MV Insurance/MV Report |____/____/____ |__________________________ |
|Time Card/Pay Period/Overtime |____/____/____ |__________________________ |
|Expense Sheet |____/____/____ |__________________________ |
|Consumer Bill of Rights - Staff |____/____/____ |__________________________ |
|Reporting Maltreatment of Minors/ Vulnerable Adult Policy & Procedures |____/____/____ |__________________________ |
|Drug & Alcohol Policy | | |
| |____/____/____ |__________________________ |
|Total Training Hours this Section: 1 |
|Within One Week | |Program Director |
| | | |
|Data Privacy & HIPAA Policy |____/____/____ |__________________________ |
|Incident Reporting Policy & Procedures |____/____/____ |__________________________ |
|Emergency Use of Manual Restraint Policy & Procedures |____/____/____ |__________________________ |
|Admissions Policy | | |
|Grievance Policy & Procedures |____/____/____ |__________________________ |
|Temporary Service Suspension/Service Termination Policy & Procedures |____/____/____ |__________________________ |
| |____/____/____ |__________________________ |
| | | |
| | |__________________________ |
| |____/____/____ | |
|Within One Week - Continued | |Program Director |
| | | |
|Participant Funds & Property Policy & Procedures |____/____/____ |__________________________ |
|Universal Precautions/Blood Borne Pathogens | | |
|Safe Transportation Policy & Procedures |____/____/____ |__________________________ |
| | | |
| |____/____/____ |__________________________ |
|Total Training Hours this Section: 2 |
|Within 30 Days | |Program Director/Designated Staff |
| | | |
|Individual participant CSSP Addendum |____/____/____ |__________________________ |
|Providing support with activities of daily living for individual |____/____/____ |__________________________ |
|participant * | | |
|Supervised on-the-job training with individual participant * |____/____/____ |__________________________ |
|Individual Participant IAPP (if applicable) | | |
|Medication Administration (if applicable) |____/____/____ |__________________________ |
|Operation of medical equipment for individual participant * (if |____/____/____ |__________________________ |
|applicable) |____/____/____ |__________________________ |
|Total Training Hours this Section: 5 Additional hours if applicable: _____ |
|Within 60 Days | |Designated Trainer |
| | | |
|Person Centered Thinking/Planning |____/____/____ |__________________________ |
|First Aid |____/____/____ |__________________________ |
|Other training topics as indicated in the CSSP: | | |
|_________________________________________________________________________| | |
|_____________ |____/____/____ |__________________________ |
| |____/____/____ |__________________________ |
|Total Training Hours this Section: 2 Additional hours if applicable: _____ |
* Indicates direct contact hours with participant
60 Day Orientation Completion Date _____/_____/_____ Total Training Hours _________
By signing below I acknowledge that the training noted above has been provided to me.
_____________________________________________________ _____/_____/_____
Employee Signature Date
_____________________________________________________ _____/_____/_____
Supervisor Signature Date
-----------------------
Staff Orientation & Training Checklist
Personal Support & Respite
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