This form is an example of a quiz for staff to complete after a training on a plan of care for a person receiving services. This may be helpful for trainings that were unable to be conducted in person. Please note, not all sections of this quiz may be applicable to all service settings and can be modified based on your program’s requirements. Review Quiz: ____________________ for ________________________ (name of plan) (name of person receiving services) Staff Name: Staff Title: Date: Levels of Supervision: What is the level of supervision the person requires at home? What is the level of supervision the person requires in the community? What is the level of supervision the person requires during the overnight shift? What is the level of supervision the person requires in vehicles? What is the level of supervision the person requires while eating? Medical: Does the person take any medications? Does the person need assistance administering their medications? Does the person have any PRN medications? Does the person have any allergies? If yes, please list them Does the person have a history of seizures? Behavioral: Does the person have a behavior intervention plan? Does the person have a history of wandering away/eloping? Does the person have a history of self-harm? If yes, what are the behaviors to be aware of and what are the types of self-injurious behaviors?
Does the person have a plan for physical interventions? Does the person have any medical diagnoses that contradict physical interventions? Are any rights restrictions in place for the person? If yes, please list them
Please place this quiz in the manager’s mailbox once completed.
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