Consumer Specific Competency Training Form (VA)

Staff or SRH Provider Name*

First NameLast Name

Office Location

Person Being Served Name*

First NameLast Name

Name of Trainer:*

First NameLast Name Credentials / Title

Date Training was Completed

Date

Training Time ( Duration of Training will be auto calculated once times are entered)*

:HourMinutesAM/PM Option

to

until :HourMinutesAM/PM Option

Please select whether training was completed on each topic. If the topic does not apply to the client select Not Applicable*

	Training Completed	Training Not Completed	Not Applicable
High Risk Plan / Protocols
Plan for Support (Goals / Objectives)
Likes and Dislikes
Community Participation
Communication Issues
Cultural Diversity Needs
Assisting w/Bed Pan or Commode
Assisting with Toileting
Incontinent Care
Emptying Urine / Colostomy Bag
Meal Planning / Clean Up
Dietary Issues
Fluid Restrictions / Intake
Spending Money / Financial Log
Understanding Behavior Plan
Behavior Specialist Contact Information
Documentation of Behaviors
Incident Reporting Procedures
ISP
Location of Emergency Contact Information
Hospital Preference
Release form for Emergencies
Intact Skin Care
Hair Care / Trimming
Shaving
Oral Care
Hand / Foot Care
Bathing / Personal Care
Partial Bath
Dressing Individual
Wheelchair Safety / Maintenance
Transferring (Bed / Chair)
Mobility Issues / Safety
Positioning / Lifting / Body Mechanics
What Person Centered Care means

Person Centered Care Talking Points:

Being Person-centered means affording people dignity, respect and compassion, whether service user or provider.
Being person-centered means the person is a partner in their own care and the health and wellbeing of the person is the focus of care, not their illness or conditions.
Being person-centered means the individual's specific needs and desired outcomes are the driving force behind all support and care the individual receives.
Being person-centered means seeing the person and not the condition/diagnosis.
Person-centered care is a way of thinking and doing things that sees the individual receiving support / service as an equal partner in planning, developing and monitoring the support and services to meet their needs.
Being person-centered means to consider the person's desires, values, family situation, social circumstances and lifestyle.
Being person-centered means understanding that there is not a one size fits all solution when planning and developing the person's support and services.
Being person-centered means to treat the person respectfully as an individual human being, not as a condition/diagnosis that needs treated

Please list any additional topics completed during the consumer specific training not listed in the checklist above:

Please list the individual's current medications, what the medication is treating and the side effects of the medication. (If individual does not take medication please state that in the box)*

EXAMPLE OF HOW TO LIST MEDICATIONS, TREATMENT & SIDE EFFECTS

Zoloft - to treat anxiety - nausea, headache, fatigue, constipation
Pantoprazole - to treat reflux - blurred vision, increased hunger/thirst, stomach pain
Tylenol - to treat generalized pain - rash, hives, red/peeling skin

Staff or SRH Provider Signature Date

Date

Staff or SRH Provider Signature - signature indicates you fully understand all the training topics completed.*

Signature of Trainer Below indicates that the employee has demonstrated the expected level of competency in the skills areas check marked above.

Trainer Signature Date

Date

Trainer Signature / Credentials*