TRAINING ATTESTATION – Completed Example
Summary of Coaching and/or Counseling Conversation
On January 1, 2026, Jane Doe, Support Staff, did not complete the required bed checks on the overnight shift. I provided the “Bed Checks Protocol” to Jane Doe and reviewed the information listed, which included that bed checks need to be completed on every overnight shift and documented in the “Overnight Sleep/ Supervision Chart” per our agency’s requirements. Jane Doe asked where they can locate a blank copy of the chart in the event they need to make more copies and I informed them the blank copies are located in the back of the communication binder, that is located in the staff office and then showed her the binder. Jane Doe did not have any follow up questions.
Signature of meeting facilitator
Printed name and title of meeting facilitator
Date
I,
, attest that the above summary is accurate.
Printed staff name
Staff signature
Staff’s printed name and title
Date
Keep this form in the employee’s training records at the program and if required, submit a copy to Human Resources.
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