Supervision Data Form PDF Details

Effective supervision and guidance is an essential component of any successful team or organization. Every leader needs to be able to collect data on their employees' performance in order to accurately assess their strengths, weaknesses, and areas that need improvement. A great way for supervisors to track employee information is through a supervision data form. By creating an organized structure, supervisors have the tools they need to document feedback and record progress over time—making it easier for themto identify key areas where changes are needed. In this blog post, we'll explore what makes up a comprehensive supervision data form and how you can use it as part of your management process.

QuestionAnswer
Form NameSupervision Data Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesflorida supervision, alabama complaint for divorce, florida mqa supervision form, florida physician assistant supervision form

Form Preview Example

Make additional copies of page 1 as needed.

SUPERVISION DATA FORM

IMPORTANT: THIS FORM MUST BE UPDATED BY THE PHYSICIAN

ASSISTANT AS A CONDITION OF PRACTICE

Pursuant to s. 458.347(7)(e) and s. 459.022(7)(d), F.S., upon employment, a licensed physician assistant must notify the

department in writing within 30 days after such employment and after any subsequent changes in supervision.

Council on Physician Assistants, 4052 Bald Cypress Way, Bin #C-03, Tallahassee, Florida 32399-3253

***** PLEASE PRINT *****

Name:

FirstMiddle InitialLast

Florida Physician Assistant license number: PA_____________________________________________________

Print your current mailing address:________________________________________________________________

All current practice locations:

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Return all 5 pages. This Supervision Data Form will not

be processed without the Physician Assistant’s signature and date.

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

1

 

I am ADDING the following supervising physician(s). PLEASE PRINT

Name and license number of supervising physician(s)

Specialty of supervising

Beginning date of

 

physician

Supervision

____________________________________________

 

 

ME or DO license number:

 

 

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

Make additional copies of page 2 as needed

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

2

 

I am DELETING the following supervising physician(s). PLEASE PRINT

Name and license number of supervising physician(s)

Effective date of deletion

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

Make additional copies of page 3 as needed

 

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

3

 

I am ADDING the following practice location(s). PLEASE PRINT

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(5) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(6) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(7) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(8) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Make additional copies of page 4 as needed

 

 

 

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

4

 

I am DELETING the following practice location(s). PLEASE PRINT

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(5) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(6) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Signature of Physician Assistant

Date of signature:

Return all 5 pages. This Supervision Data Form will not be processed without the Physician Assistant’s signature and date.

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

5

 

How to Edit Supervision Data Form Online for Free

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Step 1: Firstly, access the tool by clicking the "Get Form Button" at the top of this webpage.

Step 2: With the help of our state-of-the-art PDF file editor, you can actually do more than just fill in blank form fields. Try all the functions and make your documents seem high-quality with custom text incorporated, or adjust the file's original input to perfection - all that comes along with an ability to incorporate your personal pictures and sign it off.

This form will require particular info to be filled out, so ensure you take the time to fill in exactly what is asked:

1. The florida physician assistant supervision form involves certain information to be inserted. Ensure the following fields are finalized:

Completing section 1 of what can you put when filling out supervision forms

2. Once your current task is complete, take the next step – fill out all of these fields - Address Facility name, Street City State Zip Code, Address Facility name, Street City State Zip Code, Address Make additional copies of, and Street City State Zip Code with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling in segment 2 in what can you put when filling out supervision forms

3. Completing physician, Supervision, and ME or DO license number ME or DO is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Filling in part 3 of what can you put when filling out supervision forms

Always be extremely attentive while completing physician and Supervision, since this is where many people make errors.

4. To go forward, this fourth step requires filling out a few blank fields. Examples include ME or DO license number ME or DO, which you'll find essential to carrying on with this particular form.

Filling in section 4 in what can you put when filling out supervision forms

5. And finally, this final subsection is precisely what you will have to finish before finalizing the form. The blanks in this instance are the following: Name and license number of, and Effective date of deletion.

what can you put when filling out supervision forms completion process outlined (part 5)

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