clements centre society section 2 - forms personnel formsclements centre society section 2 - forms...

Clements Centre Society

Section 2 - Forms

Personnel Forms

2.1 Community Living Hiring

2.1.1 Letter of Introduction

2.1.2 Application for Employment (2 pages)

2.1.3 Shortlist Qualification Tabulation Form

2.1.4 Qualifications and Ability Scoring Guidelines– Community Support Worker

2.1.5 Interview Forms – Tabulation Worksheet

2.2 Child Development Hiring

2.2.1 Pre- Screen Guidelines - CCRR

2.2.2 Pre-Screen Guidelines - IDP

2.2.3 Pre-Screen Guidelines - Therapists

2.2.4 Hiring Score Sheet

2.3 Reference Check Form

2.4 Recommendation For Position

2.5 Community Living Orientation

2.5.1 Hiring Checklist

2.5.2 General Orientation Checklist

2.5.3 Residential Orientation Checklist

2.5.4 Day Program Orientation Checklist

2.5.5 Children’s Family Support Program Orientation Checklist

2.5.6 Managers Checklist

2.5.7 General Service Policies

2.6 Availability

2.6.1 Availability – Casual Employees

2.6.2 Availability – PPT Employees

2.7 Conduct Agreement

2.8 Employee Release of Information

2.9 Exit Questionnaire

2.10 Medical Report

2.11 Orientation Evaluation


Section 2 - Forms

2.12 Performance Review

2.12.1 Probation Review

2.12.2 Community Support Worker

2.12.3 All Other Employees

2.12.4 Manager Feedback from Direct Reporting Staff

2.12.5 Performance Review – Executive Director Feedback from Board

2.12.6 Peer Review

2.13 Professional Development Request

2.14 Vacation Request

Universal Forms

2.15 Building Rental

2.16 Complaint Report

2.17 Media Consent

2.18 Release of Client Information


Section 2 - Forms

2.1.1 COMMUNITY LIVING – LETTER OF INTRODUCTION

Before you complete the attached application form, we would like to provide you with some information

regarding our organization and our expectations of all employees.

CCS is a board driven, non-profit society proud to have provided service to the Cowichan Valley since

1957. CCS provides programs and advocacy for adults who are referred for services through Community

Living BC, and children at risk for a developmental disability. CCS serves approximately 300 individuals

through adult day programs, adult residential services, and child development services. Our geographical

boundaries extend from Saltair to the Malahat and west to Lake Cowichan.

Our Vision is: CCS envisions a community in which all individuals

are included, accepted, and valued.

Our Mission is: We support citizens of the Cowichan Valley to participate meaningfully

in all aspects of community life. We provide child development services

and services for adults, primarily for those with developmental

disabilities.”

Our Values are: Valued Equally: Each individual has intrinsic worth.

Human Potential: Each individual’s capability can be realized.

Integrity: To conduct oneself with honesty, trustworthiness and

incorruptibility.

If you are applying for a casual position with Community Living Services, you should be aware of our

availability requirements. These requirements have been developed in the best interest of the people we

serve. A casual employee is one who is employed for work that is not scheduled on a regular basis:

“Casual employees shall at a minimum be prepared to work in all CCS programs in the department of

initial hire.”

It is important for you to be aware that if an offer of employment is made, you are required to provide all

the supporting documentation (i.e.: criminal record check, etc.), prior to your first work shift in your

program of hire.

Please note that we will check the references of past employers indicated on the attached application

form, and may verify stated education and professional status. Your cooperation in providing complete

information is appreciated.

If you are interested in joining our valued team of staff please complete the attached form or contact our

administration department at [email protected] or 250-746-4135.

mailto:[email protected]


Section 2 - Forms

2.1.2 COMMUNITY LIVING – APPLICATION FOR EMPLOYMENT

Name ________________________________________________________________________________________________________________

Last First Middle Telephone

Address_______________________________________________________________________________________________________________

Number Street City Province Postal Code

Fax _________________________ E-mail _____________________________ Pager ____________________

Are you legally entitled to work in Canada? ________________

Position applying for: ___________________________________________________

Competition #____________________

Availability: When available (date):_______________ Full time Part time Casual

Is there any time/day that you would not be available:_______________________________________________________________

Should CCS make an offer of employment, this offer will be contingent upon acquisition of the following certifications and letter. Employees of

community living programs must have a Class 4 Drivers License: (Please note when the certifications/letters were acquired and/or expiry date.)

BC driver’s license: (____) Exp._____________________ WCB First Aid & CPR: (____) Exp.____________________

(Class)

TB test (negative): (____) Acquired Date:_____________ Criminal record check: (____) Acquired Date:____________

Food Safe:____________________________________

Education Name City Dates Diploma/Certificate

Secondary

Post Secondary

Other relevant education

and/or workshops (attach list if required)


Section 2 - Forms

Employment History (list most recent employer first)

Employer/Address Direct Supervisor Telephone Position/Duties From -To

(Dates)

Reason for leaving

Please complete the name, address and phone number of your previous employers.

Do you have any physical or emotional health issues that could interfere or prevent you from:

a) Performing daily client transfers and lifts? (If Yes, please explain)

____________________________________________________________________________________________________

b) Dealing with aggressive or self-injurious behaviour? (If Yes, please explain)

______________________________________________________________________________________________________________

c) Completing household duties and yard work? (i.e. mowing, raking, vacuuming, carrying groceries, cleaning)

______________________________________________________________________________________________________________

Why would you like employment with Clements Centre Society? _________________________________________________________

___________________________________________________________________________________________________________________

Where did you hear about this position?__________________________________________________________________________________

CERTIFICATE OF APPLICANT: By signing this application for employment, I authorize CCS to obtain information regarding my previous employment and/or education. I

hereby certify the above to be correct, that all statements made in this application are true, and I agree and understand that any misrepresentation of material facts herein will cause

forfeiture on my part of all rights to any employment by CCS.

Signature: __________________________________________________ Date: _____________________________


Section 2 - Forms

2.1.3 COMMUNITY LIVING - SHORTLIST

Qualification Tabulation form

Competition #:_________________________ Evaluator(s): __________________________

Name Inter

view

Experience Pts CSW/Education pts total App d-lic 1st tb cpr crc food

safe

Dr.

ltr

Notes

y/n Refer to evaluation

sheets – provide subtotals

7 Refer to evaluation sheets

- provide subtotals

13 Max 20


Section 2 - Forms

2.1.4 QUALIFICATIONS AND ABILITY SCORING – CSW

SECTION 1 – QUALIFICATIONS

1.1 Formal Education – 15 Points Maximum

( ) CSW, CYC Diploma, Human Service Worker – 15 points

( ) BA/BSC Human Services (psychology, sociology, criminology, etc.) – 15 points

( ) RCA/LTC – 10 points

( ) Human Service certificates (ie: ECE, TA) – 10 points

( ) Other certificates (ie: Mental Health, etc.) based on duration – 6-8 points

( ) Grade 12 – 5 points ______/15

1.2 Relevant Workshops – 10 Points Maximum

1 point per relevant course (excluding hiring requirements) ______/10

_________________________________

Qualification Total (T1): ______/25

SECTION TWO – ABILITIES

2.1 Previous Relevant Experience – 25 Points Maximum

Applicants are required to have a minimum of 1 year (or equivalent hours) experience in each

relevant area to score.

Experience:

( ) Exactly as posted position (program, client group, shift, etc.) – 25 points

( ) Supporting specified position’s client group (mental health/behavioral, high health, non-

ambulatory, adults, children, etc.) in community & licensed facility – 20 points

( ) Supporting specified position’s client group in community-based program – 18 points

( ) Supporting specified position’s client group in facility-based program – 18 points

( ) Supporting individuals with developmental disability in community and/or licensed facility –

15 points

( ) Supporting individuals with DD (private home, home share, TA) – 10 points

( ) Supporting individuals with special needs – 8 points

( ) Volunteer or practicum with client group – 5 points

( ) No experience – 0 points ______/25

2.2 If position is a different job description than any applicants have experience in

AND/OR

If all candidates’ scores are less than 15,

Proceed to interview (Alternate score from interview) OR ______/25

______________________________________

Abilities Total (T2) _______/25


Section 2 - Forms

SECTION THREE – PERFORMANCE

3.1 Scoring from performance reviews Performance Total (T3): ______/25

SECTION FOUR – SENIORITY

4.1 # of Years (___hrs. = 1 year) Seniority Total (T4) ______/25

TOTALS SECTION

Line T1 Qualifications ________

Line T2 Ability ________

Line T3 Performance ________

Line T4 Seniority ________

________________________________

Add lines T1 to T4: Line T1 ________/100(%)

Seniority (date or hours):_____________________________________________


Section 2 - Forms

2.1.5 INTERVIEW FORMS - Tabulation Worksheet

Interviewers 1) ____________________ 2) _____________________________

Competition Number: __________________________ Date: ________________

People Interviewed

1) ____________________ Seniority Hours: ____________ Status (Casual/ PT/ FT): _________

2) ____________________ ____________ _________

3) ____________________ ____________ _________

4) ____________________ ____________ __________

Abilities Total Total Total Total

Rating a 4

Rating b 4

Rating c 4

Rating d 4

Rating e 4

Reviews 10

30

Qualifications

Certificate/

diploma or

CCS hrs

10

Workshops

3

Previous

Experience

7

SUBTOTAL 50 /50 /50 /50 /50

Presentation

Punctuality 1

Appearance 1

Demeanour 1

3

Skills/Knowledge

Question 1 2

Question 2 4

Question 3 4

Question 4 4

Question 5 4

Question 6 4

Question 7 4

Question 8 4

30

Written

Content 4

Presentation 3

7

TOTALS 90 /90 /90 /90 /90


Section 2 - Forms

2.2.1 CHILD DEVELOPMENT – Pre Screen Guidelines for CCRR

CCS Child Development Team, CCRR Pre Screen Education & Previous Experience

Applicant Name: ______________________ Date: _______________________

Evaluator Name(s): ____________________ Competition #: ________________

Relevant Education – 10 points maximum

Masters Degree in Related Field – early childhood education, child and youth, education, etc.

– 5 points

Undergraduate Degree in Related Field –early childhood education, child and youth,

education, etc. – 5 points

Early Childhood Care and Education Certificate – 3 points

Unrelated Degree – 2 points

Other related certificates or diplomas – 1 points

Related courses – 1 points

Previous Relevant Experience – 5 points maximum

Experience in CCRR programs – 5 points

5 years or more experience in child care -4 points

2 to 5 years experience in child care – 3 points

3 years or more experience in related field - 2 points

Other Related and Relevant Experience – 1 point each for a maximum of 5 points

Direct experience in CCRR

Direct experience in child care

Experience working with families

Demonstrated knowledge of computers

Experience in adult education and training (formal and informal)

Example:

Taught at the post secondary level

Taught community education courses for adults

Presented workshops to groups of adults

Made presentations to adults

Worked with individuals to increase skill level (informal)

Modeling of appropriate interactions (informal)

Sharing information on a one to one basis

Total Score: ______________

Recommend for an interview: yes no

Notes:


Section 2 - Forms

2.2.2 CHILD DEVELOPMENT - Pre Screen Guidelines for IDP

CCS Child Development Team, IDP and FSC Pre Screen Education & Previous Experience




Masters Degree in Related Field - child and youth, education, nursing, psychology, sociology

etc. – 5 points

Undergraduate Degree in Related Field –child and youth, education, nursing, psychology,

sociology etc. – 5 points

One-year Diploma in Infant Development – 4 points

Early Childhood Care and Education Certificate – 3 points

Unrelated Degree – 3 points

Other related certificates or diplomas – 2 points

Related courses – 2 points


5 years or more experience in IDP -5 points

2 to 5 years experience in IDP – 3 points

1 to 2 years experience in IDP – 2 points

5 years or more experience in related field - 2 points

Other Related and Relevant Experience - 5 points maximum

Working with infants, including those with developmental challenges – 1 point

Working with people with diverse backgrounds – 1 point

Case management experience – 1 point

Facilitating relevant inter-agency collaboration (health; medical;

social service; education services) – 1 point

Assessment skills and program planning

Family-centred practice – 1 point

Working as a member of an inter-disciplinary team – 1 point

Total Score: ____________


Notes:


Section 2 - Forms

2.2.3 CHILD DEVELOPMENT - Pre Screen Guidelines for Therapists

CCS Child Development Team, Therapist Education & Previous Experience




Licensed to practice specific therapy (certified or registered) in BC – 5 points

Masters Degree in specific therapy - 3 points

Undergraduate Degree in specific therapy – 2 points

Paediatric courses – .5 points per course to a max of 2 points


2 years or more paediatric experience -5 points

1 or 2 years paediatric experience – 3 points

2 or more years direct therapy experience – 2 points

No experience, specific paediatric training -1 point

Other Related and Relevant Experience - 5 points maximum

Working with people with diverse backgrounds – 1 point

Case management experience – 1 point

Facilitating relevant inter-agency collaboration (health; medical;

social service; education services) – 1 point

Working in community based programs -1 point

Family-centred practice – 1 point

Working as a member of an inter-disciplinary team – 1 point

Total Score: ____________


Notes:


Section 2 - Forms

2.2.4 CHILD DEVELOPMENT - Hiring Score Sheet

Competition Number: ____________ Name of Applicant: ___________________

Date: ________________________ Position: ___________________________

Service Qualification Scoring

Education: As per the pre screen Experience: As per the pre screen

TOTAL SERVICE QUALIFICATION POINTS: _______/20

COMMENTS:

____________________________________________________________________________

____________________________________________________________________________

Interview Rating

Knowledge Notes Points (5

per

question)

Question 1

Question 2

Question 3

Question 4

Skills

Question 1

Question 2

Question 3

Question 4

Total for questions

Total for questions plus

qualifications

SUPPORTING DOCUMENTATION

3 References

Criminal Record Check

Check of Certification

Interviewer: _______________________________________

Recommend for hire: yes/no


Section 2 - Forms

2.3 REFERENCE CHECK FORM

Applicant’s Name: _____________________________________________________________

Reference Name: _________________________________ Phone #: _______________

Reference Check Conducted By: _____________________ Date: ____________

To start

Identify yourself and CCS.

Verify that you are speaking to the person named as a reference.

Tell the person that the applicant gave you permission to call for a reference, they are one of several, and that you will keep the conversation confidential.

Ask if this particular time is suitable and indicate how long it will take for the conversation.

Explain what the applicant would be doing for CCS and the client group they would be working with.

Once the questions have been answered – thank the person for their time.

1. How long have you known _____________________ and in what capacity?

2. In your opinion, does the applicant follow through on his/her obligations/commitments?

Comments?

3. On a scale of 1-4 (1 being inadequate & 4 being excellent) how would you rate: inadequate………………excellent a. demonstrated ability to plan, offer & implement ideas,

promote community inclusion? 1 2 3 4

b. organization skills, ability to work independently,

ability to complete routines as outlined? 1 2 3 4

c. ability to work with a team and relate client needs

with respect, and good communication skills? 1 2 3 4

d. self motivated, reliable, has good attendance? 1 2 3 4

e. demonstration of professionalism/ leadership? 1 2 3 4

f. rate overall performance? 1 2 3 4

5. Please identify: Strengths:

Areas that could be improved:

6. Did he/she leave of their own accord?______. Would you rehire him/ her?______

7. Any comment regarding interpersonal skills when interacting with the manager?

8. Do you have any other information pertinent to this applicant?


Section 2 - Forms

2.4 RECOMMENDATION FOR POSITION

Position: _____________________________________________________________________

Competition Number: ___________________________________________________________

Hiring Committee Members: _____________________________________________________

The Hiring Committee makes the following recommendations:

For Step 2 – First Process - 5th

Bullets – recommend yes or no to advertise external at end of 7th

day.

Comments: ________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________

Hiring Committee member: ________________________________ Date: _______________________

For Step 2 – First Process – 4th

and/or 11th

Bullet – Short list (use for 4.1)

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

_________________________________________________________________________________

Hiring Committee member : ________________________________ Date: _________________________

For Step 4 – First Process – 5th

Bullet – recommend following:

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

_________________________________________________________________________________

Accepted by Program Director: ________________________________ Date: _________________________

Reference Checks by:

_____________________________________________________________________

Comments (if any):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Approval for offer of employment by Executive Director:

Signature: ______________________________ Date: _____________________________


Section 2 - Forms

2.5.1 HIRING CHECK LIST

Name: _________________________________________________

Date of Hire: ____________________________________________

1 Application Form

2 Resume

3 TD 1 Form

4 Direct Deposit

5 Conduct Agreement Form

6 Criminal Record (6 months or less) (original or our photocopy from original)

7 Driver’s License (our photocopy from original)

8 Class 4 License (our photocopy from original) For more information visit:

http://www.yourlibrary.ca/driving/

9 First Aid Certificate (original or our photocopy from original)

10 Emergency Contact Information

11 Immunization (original or our photocopy from original)

12 TB Test (1 year or less) (original or our photocopy from original)

13 Hiring Letter

14 First Day of Work

15 General Service Policy Signed

16 Orientation Check List Done

17 Post Secondary Certificate (original or our photocopy from original)

18 Certification letter (therapies) (original or our photocopy from original)

19 Food Safe (original or our photocopy from original)

20 Orientation

21 Orientation Evaluation

Notes:________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

This form should be initiated for a person short-listed and flow through telephone

interviews, formal interview, and recommendation to hire and to payroll.

Relevant documentation to be attached

http://www.yourlibrary.ca/driving/


Section 2 - Forms

GENERAL ORIENTATION CHECKLIST

Administration: Emergency at Clements

____ Executive Director ____ fire pulls

____ Director of Finance ____ extinguishers

____ Accounting Assistant ____ emergency response guide

____ Administrative Assistant ____ exits

____ Program Director ____ first aid kits (LOC & Foyer)

____ Policy and Committee Minutes Binders ____ earthquake drills & kits

____ Postings/Professional Development/Workshop info.

Clements St. Building: Human Resources (with Accounting Assistant)

____ Lunch on Clements ____ payroll – how/when/timesheets

____ Supported Employment ____ benefits

____ Child Care Resource & Referral ____ travel/mileage

____ Supported Independent Living ____ performance reviews

____Toy lending Library ____ holiday procedure

____ Activation Leisure ____ absenteeism reporting

____ Mail Room ____ agency policy manual

____ Washrooms ____Employee Family Assistance

____ Child Development

____ Lunch Room

____Break out rooms – board & other

CCS Facilities: Sign up for Volunteers

____ Residential Programs ____ Confidentiality

____ Criminal Record Search

____ Collective Agreement

____ Physician’s Letter

____ Letter of Hire

____ TB Test

____ Drivers License

____ First Aid Certificate

____ Reference Checks

STAFF SIGNATURE: __________________________________________________________

*This information is meant to complement any program or volunteer specific orientation


Section 2 - Forms

2.5.2 RESIDENTIAL ORIENTATION CHECK LIST Administration Orientation

R

C

M

GENERAL

Mission statement, vision, values, principles (Sec 1.2) – how that is reflected in day-to-day work.

CCS Principles and Procedures Manual:

Online and hard copy

Expectation for completion

Probation self assessment questionnaire

CLBC/Critical Incident: Service Provider Requirements/ Behavioural Support & Safety /Bathing Guidelines

VIHA/Community Care and Assisted Living Act/Residential Care Regulations/Licensed facilities

BCGEU collective agreement – Shop steward, contract Union Bulletin Board, OSH & JLM committee

Paydays, time sheets, casual mail

Relief call out, casual protocol (Sec 1.4 and 1.18)

Confidentiality, privacy, and, consent (Sec 1.6 and 1.32)

Professionalism, team work, and consistency

Health and safety concerns, repair requests (Sec 1.48.2 and 1.30)

Complaints procedures (Sec 1.35)

Universal precautions (Sec 1.53.6)

Telephone and computer use (incl. long distance, house cell phones, etc) (Sec 1.24)

PROGRAM

Tour of home:

Location of fire extinguishers/exits, electrical box, water & gas shut off,

First aid kits, earthquake kit, Emergency Response Guide

Meds

Staff mail, memos, staff schedule, meeting minutes

Keys, relief/hidden keys

Location of logs, blank forms, other information, and petty cash

Menu, grocery shopping, documentation of menu change

Emergency procedures, emergency contacts, drills (Sec.1.50.1 and 1.50.2)

Critical Incident reporting, internal incidents (Sec 1.52)

Shift routines/Outings (Sec 5.2.10)

Household Expenditures: (Sec 5.2.7)

Charge accounts

Petty cash

Receipts and documentation

Safe lifting practises (1.53.2)

Vehicle: (Sec 1.56)

Gas fill up

Emergency equipment and procedures

Documentation - Pre-trip, mileage, accidents/damage

Use of own vehicle, insurance requirements, documents to Admin

Use of van lifts and tie downs

INDIVIDUAL

Individual files/logs, profile of each resident, key workers (Sec 5.2.1-5 and 5.2.11)

Documentation i.e. logs, charts, appointments

Health Care Plans, Medication Procedures, PRN protocols, Hygiene (Sec 5.2.22)

Service Plans - Goals and outcomes (ISPs and IPPs) (Sec 5.2.3)

Behaviour and Safety plans

Banking and personal spending (Sec 5.2.6 and 5.2.8)

Day Programs (individual schedules)

I, __________________________________, have reviewed and understand the above principles and procedures and agree to

read all CCS policy by the end of my probation period.

Signature:_______________________________________ Date:________________________


Section 2 - Forms

2.5.4 DAY PROGRAM ORIENTATION CHECK LIST

Administration Orientation

A

L

SI

SE

SCow

PROGRAM

Tour of program (location of fire extinguishers/exits, First aid kits and records, earthquake kits,

keys, electrical box, water shut off, med cupboard, file cabinets, notice board, van, meds, and

petty cash receipts), memos, staff schedule

Emergency procedures and drills (fire/earthquake)

Confidentiality/Privacy/Consent (Sec 1.6 and 1.32)

Team work/consistency/professionalism

Staff meeting minutes, mail slots, client files

Vehicle (gas fill-up, first aid, emergency procedures), pre-trip inspection, use of personal

vehicle

Staff phone numbers (not given out), long distance calls, cell phone, phone lists, telephone

policy, computer use

Pay days, time sheets, casual mailbox (at office)

Shift routines, breaks, work schedules, activity calendar

Relief call out, casual protocol(Sec 1.4 and 1.18)

Shop steward – Contract – Union Bulletin Board – OSH Committee – JLM Committee

Marking information on calendars (A/L,) vehicle sign out, LOC & A/L room bookings

Clients not left alone

CLIENTS

Individual files/information/profile of each client, key workers(Sec 5.2.1-5 and 5.2.11)

Logs, charts, documentation

ISP’s, PSP’s, service plans & goals (key worker binder) (Sec 5.2.3)Outcomes

Behavioural & Safety plans

Personal floats

Health Care Plans/medications procedures(Sec 5.2.22)

Outings (policy & individual schedules

I have reviewed and understand all of the above:

Signature: _______________________________________ Date: _________________________ Jan 10.07

POLICIES AND PROCEDURES (complete read by end of probation – available online)

Mission statement, vision, values, principles (Sec 1.2) – CCS Policy and Procedures Manual,

Admin policies, Ministry policies, Board policies and procedures, day program philosophy &

application

Universal precautions(Sec 1.53.6)

General service policies

Incident reporting (critical and internal)(Sec 1.52)

Smoking/alcohol policy

Complaints/ Concerns Report(Sec 1.35)

Holidays/relief


Section 2 - Forms

2.5.5 CHILDREN’S FAMILY SUPPORT PROGRAM ORIENTATION

CHECK LIST

Administration Orientation

CFS

PROGRAM

Tour of program (location of fire extinguishers/exits, First aid, earthquake kits, keys, electrical box, water

shut off, med cupboard, file cabinets, notice board, van, meds, and petty cash)

Emergency procedures

Vehicle (gas fill-up, first aid, and emergency procedure), lifts, vehicle equipment

Staff phone numbers (not given out), long distance calls, cell phone, phone lists, telephone policy

Pay days, time sheets, casual mailbox (at office)

Shop steward – Contract – Union Bulletin Board – OSH Committee – JLM Committee

Marking information on calendars

CLIENTS

Individual files/information/profile of each client, key workers

Logs, charts, documentation

Medical protocols: seizures, PRN’s, MARS

ISP’s, PSP’s,

Crisis intervention, behavioural or other support plans

Signature: __________________________ Date: ________________ Jan 10.07

POLICIES AND PROCEDURES

Mission statement, vision, values, principles – CCS Policy and Procedures Manual

Fire drills, earthquake and where to document

Activity Calendar

Petty Cash

Job descriptions

Universal precautions

General service policies (13)

Logs (communication and personal)

Incident reporting

Holidays/relief

Corrective discipline

No show/ Not at home policy

Release policy/approval


Section 2 - Forms

2.5.6 MANAGERS CHECKLIST Administration Orientation

PROGRAM

Tour of home (location of fire extinguishers/exits, First aid, earthquake kits, keys, electrical box, water &

gas shut off, call buttons, med cupboard, file cabinets, freezer, notice board, non-prescription meds and aids,

van, meds, relief keys and petty cash)

Maintenance – emergency equipment/lighting, vehicles, home

Program orientation checklist

POLICIES AND PROCEDURES

Mission statement, vision, values, principles – CCS Policy and Procedures Manual

Strategic plan

Complaints/Concerns policies

CLBC Policies – General Service Policies

Licensing Regulations and relationship – investigations etc. (group homes only)

VIHA (LOC only)

FOIPOPA Legislation and agency policy

Collective Agreement – OSH Committee, JLM Committee

CARF standards – relevant sections

REPORTING

CLBC – both residential and non-residential

Report to Board of Directors

Annual Report to the Board

Connector

Outcomes

HEALTH & SAFETY

Agency Procedures

Medication procedures

Monthly & quarterly reports, first aid & earthquake kits

Monthly vehicle inspections including emergency supplies

Regular Drills

CLIENTS

Introduction and history

Planning Processes

Service Plans (including as appropriate: health care, oral health care, behavioural, safety etc.)

Documentation and File information

HUMAN RESOURCES

Hiring procedures – both internal and external

Performance planning – probation/trial/annual

Staff orientation and ongoing training

Scheduling and time sheets

Staff meetings

Managers meetings

Corrective Discipline

Expense tracking/approval/submission

Signature: _______________________________________ Date: ___________________________ (June 2010)


Section 2 - Forms

2.5.7 GENERAL SERVICE POLICIES

As a contractor with Community Living B.C., the Clements Centre Society– adult services, are mandated

to comply with the following guidelines:

RE: Behavioural Support and Safety Planning

Critical Incidents: Service Provider Requirements

Bathing Guidelines

Investigation of Abuse and Neglect

The “Behavioural Support and Safety Planning” policy introduces guidelines for supporting individuals

with challenging behaviours and clarify CLBC’s role in monitoring adherence to these guidelines. This

policy replaces “guidelines for Use of Behavioural Techniques”.

The policy “Critical Incidents: Service Provider Requirements” includes the requirement to report, the

definitions of reportable critical incidents and the procedure for reporting. The guidelines for reporting

are also outlined in Clements Centre agency policy.

The “Bathing Guidelines” assist service providers in developing bathing practices that respect an

individual’s wish for privacy when bathing or for assistance with other personal care activities while

addressing possible risk.

The policy on “Investigation of Abuse or Neglect” describes the roles and responsibilities of all involved

parties and the procedure that is followed in responding to allegations of abuse.

If you have any questions, comments or concerns please contact your immediate supervisor or consult

your program or home Policy & Procedure manual.

To be completed by Employee

I have read, understood and agree to comply with the policy in the “Guidelines for Use of Behavioural Techniques” and the requirement to report any critical incident involving an adult participant referred through CLBC.

___________________________________________ _____________________________

Signature Date

___________________________________________ _____________________________

Witness Date


Section 2 - Forms

2.6.1 AVAILABILITY FORM – CASUAL STAFF

Employee: ________________________________ Effective Date: _____________________________

1. For the period of: The month of ____________________ only:

Or until revoked by the employee on or before the 25th

day of any month, subject to a

new filing at least every 6 months from the date of the last filing. (Availability times will be rolled over starting

from the first Sunday in the month to the first Sunday in the next month up to end of the 4th

complete week

(Sunday to Saturday). The “stub” days (not complete weeks) at the beginning and end of the month will be

filled in similar to the first week for the start of the month, and the last week for the end of the month.

2. Please indicate as applicable (more than one may be checked):

I am available to work a sixth day in a week in order to add to my regular hours to reach the maximum

regular hours permitted in a work week in my department.

I am available for Immediate & Short Notice Shifts if the list is exhausted the 1st time through the call list

or;

I wish to be available for Immediate & Short Notice Shifts if the list is exhausted and overtime will be

offered.

I wish to be contacted for a block that totals 84 hours or more, even though my form indicates I may not be

3. Casual Employees MUST be available for one of these two days, CAN opt for both and MUST indicate by

September 01:

I am available for Christmas Day and\or;

I am available for New Years Day.

4. Please indicate the day’s and\or times that you are NOT available for work:

If only the day is checked the unavailable time will be all shifts from midnight to midnight, otherwise state the

hours you are not available on any marked day. A day not marked means the employee is available all day,

midnight to midnight.

One may attached a calendar marked with the days and times not available. Calendar page attached or

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

And\or specify hours not available, for each day below or on an attached list.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5. My contact numbers are:

Primary: _____________________ text answering service

Others: _____________________ text answering service


Email: _____________________ use for leaving notice of shifts

Date: ______________________________ Signature: _______________________________________

Admin: date and time received: ______________________________


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2.6.2 AVAILABILITY FORM – PART TIME STAFF

Employee: ________________________________ Effective Date: _____________________________

1. For the period of: The month of ____________________ only:

Or until revoked by the employee on or before the 25th

day of any month, subject to a

new filing at least every 6 months from the date of the last filing. (Availability times will be rolled over starting

from the first Sunday in the month to the first Sunday in the next month up to end of the 4th

complete week

(Sunday to Saturday). The “stub” days (not complete weeks) at the beginning and end of the month will be

filled in similar to the first week for the start of the month, and the last week for the end of the month.

2. Please indicate as applicable (more than one may be checked):

I am available to work a sixth day in a week in order to add to my regular hours to reach the maximum

regular hours permitted in a work week in my department.

I am available for Immediate & Short Notice Shifts if the list is exhausted the 1st time through the call list

or;

I wish to be available for Immediate & Short Notice Shifts if the list is exhausted and overtime will be

offered.

I wish to be contacted for a block that totals 84 hours or more, even though my form indicates I may not be

I am willing to change my PPT shift to accept a block if I receive more hours than my present PPT position

in a week. I understand that this change is permitted only for block bookings.

I do not wish to change my PPT shift, but would consider block postings for additional hours if the blocks

do not overlap my regular PPT shift.

I do not wish to change mu PPT shift, but am available as marked.

3. PPT Employees must indicate by September 01:

I am available for Christmas Day and\or;

I am available for New Years Day.

4. Please indicate the day’s and\or times that you are NOT available for work:

If only the day is checked the unavailable time will be all shifts from midnight to midnight, otherwise state the

hours you are not available on any marked day. A day not marked means the employee is available all day,

midnight to midnight.

One may attached a calendar marked with the days and times not available. Calendar page attached or

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

And\or specify hours not available, for each day below or on an attached list.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5. My contact numbers are:

Primary: _____________________ text answering service



Email: _____________________ use for leaving notice of shifts

Date: ______________________________ Signature: _______________________________________

Admin: date and time received: ______________________________


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2.7 CONDUCT AGREEMENT

As an employee of Clements Centre Society (CCS), I ______________________________

agree to the following:

I understand and agree to CCS’s Vision, Mission, Code of Ethics, Values and Principles.

I understand and agree to keep confidential all client information. Information entrusted

to me will only be shared in a professional or advocacy capacity with the full knowledge

of my immediate supervisor.

I agree not to deliberately divulge any confidential information that would harm or

undermine the effectiveness and reputation of CCS.

I understand that this agreement will form part of my personnel record and will remain in

effect for the duration of my employment position with CCS, regardless of position or

worksite.

I understand that the obligation to maintain confidentiality continues indefinitely.

I understand that violation of this agreement in any way may result in discipline up to and

including suspension or dismissal from my employment position with CCS.

I have read and understand the attached ‘Conflict of Interest including Outside

Employment and Gifts’.

I will not compete against CCS for business.

Signature: ______________________________________ Date: ______________________

Witness: _______________________________________


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2.8 EMPLOYEE RELEASE OF INFORMATION

(See Personnel Practices, confidentiality, criminal record check, and employee record

management)

I, ______________________________________________________

give my consent for CCS staff to share the following information:

(Type of report or specific information)

to share the information with:

(Agency and/or person who will receive the information)

To share the information from:

Effective from: (date) ____________________ to _________________________

_________________________________________

Signature


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2.9 EXIT QUESTIONNAIRE

This information is confidential and will not form a part of your personnel file. Please complete and

return to accounting.

To be completed by employee or employee’s supervisor.

Completed by _________________________________________________________________

Date of hire ___________________________Job classification __________________________

Last day of work _____________________

Regular full-time Regular part-time Casual

Union member or Exempt

Gender Female Male

Age under 25 25-35 36-45 46 -55 56+

Reason for leaving Education (return to school) Promotion

Transfer/move to new community Discharged for cause

Retirement Don’t like my job

Personal or family issues Increase in hours of work

Increase in wages/benefits Other

Working conditions (please specify) ______________________

______________________________________________________

What was it like to work for the Clements Centre Society?

__________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you have any suggestions on how the work environment might be improved?

__________________________________________________________________________________________________________________________________________________________________________________________________________________ INSTRUCTIONS; CSSEA members are required to complete an Exit Interview Form whenever an employee

terminates employment. • The document is to be retained in the agency files until the information is required to

complete the Employee Turnover Survey. Members are then required to complete the Employee Turnover Survey

when CSSEA collects sector-wide employee turnover data each June and December, commencing June 2008.


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mail to: Clements Centre Society 5856 Clements Street Duncan, BC V9L 3W3 fax to: 250.746.1636

2.10 MEDICAL REPORT (To be completed by attending physician)

Patient’s name: _________________________________________________________________

Date of injury/illness: __________________ ___ Date of first visit: _______________________

Date of most recent visit: __________________ Date of next planned visit: _________________

Patient Limitations

Is the patient dealing with functional limitations from medication or treatment? Yes ( ) No ( )

(If yes, please specify) _______________________________________________

__________________________________________________________________

__________________________________________________________________

Is the patient dealing with physical limitations because of illness/injury? Yes ( ) No ( )

(If yes, please specify) _______________________________________________

__________________________________________________________________

__________________________________________________________________

Is the patient dealing with cognitive limitations because of illness/injury? Yes ( ) No ( )

(If yes, please specify) ________________________________________________

___________________________________________________________________

___________________________________________________________________

Ability to Work

While undergoing treatment, is the patient able to work full-duties, full-time? Yes ( ) No ( )

If ‘no’, while undergoing treatment, can the patient work part-duties, part-time? Yes ( ) No ( )

If the patient is able to work part-duties, what duties cannot be performed?

___________________________________________________________________________

___________________________________________________________________________

If the patient is able to work part-time, how many hours per day?______________________

Return to Work

When do you expect the patient to be able to resume full duties, full time? __________________

Physician Information

________________________________ ____________________________________

Name of Attending Physician (please print) Specialty (if applicable)

______________________________________________________________________________

Address

________________________________ ______________________________

Phone Number Fax Number

_______________________________ ________________________________

Physician’s Signature Date: (day / month / year)


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2.11 ORIENTATION EVALUATION

Name: ___________________________ Date______________

o Residential

o Day Programs

o Child Development Services

To ensure orientations are a positive training experience, please be specific in answering these

questions and return in a sealed envelope to “Programs Director”. This should be filled out

before or at your probationary review and in any case, no more than ninety days after your 1st.

shift.

1. Were you made to feel welcome?

2. Were you given a thorough tour of the worksite(s)?

3. Was the orientation well organized, clear and was your time used effectively? If not, how

could your time have been better utilized?

4. Did the supervisor(s) participate in your training & make themselves available

to answer your questions and /or concerns?

5. Did the program(s) provide you with enough verbal and written information

(i.e.: policies, procedures, emergency response, protocols, and individual client

information)

6. Were you well informed about the daily routines and duties of the job?

7. Do you understand the program objectives?

1. How could we have improved your training?

2. Any other comments and/or suggestions?


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2.12.1 PERFORMANCE REVIEW - PROBATION REVIEW

Employee Name: __________________________________ Start Date: _______________________

Date of Review: _________________ Work Placements to Date: ______________________________

Completion and Submission Process 1. The Supervisor must complete the below areas using the following ratings: A: Above

standard; C: Competent; M: Marginal; I: Inadequate; U: Unable to Assess.

2. Casual staff who wishes to note their comments on the form must initial them, a separate page

can be attached.

3. Place the Review in a sealed envelope and forward it to the Accounting Assistant.

Area Self Final

Rating Rating

1. Job Knowledge. Measures understanding of the job, including regulations & policies. _____ _____

2. Application of Duties. Measures thoroughness, application of

knowledge, need for check or review. _____ _____

3. Quantity of Work. Measures volume and output of work. _____ _____

4. Judgment. Measures sound decision making ability without delay. _____ _____

5. Oral and Written Communication. Measures effective of gaining understanding with these mediums. _____ _____

6. Planning and Organization. Measures efficient application of duties, including clear goal setting _____ _____

effective use of time, ability to task focus and follow through.

7. Initiative. Measures energy, drive and enthusiasm _____ _____

8. Adaptability. Measures flexibility, ability to adjust to change _____ _____

9. Ability to Deal with Others. Measures stress tolerance and professionalism _____ _____

10. Attendance. Punctuality; appropriate use of sick time and consistent attendance. _____ _____

Describe any significant areas needing improvement __________________________________________

____________________________________________________________________________________

Describe any significant accomplishments __________________________________________________

____________________________________________________________________________________

[ ] Preliminary [ ] Recommend Extension [ ] Probation Review Passed Subject to Achieving Hours

Employee Agrees: _____ Disagrees: _____ Signature:_____________________________________

Supervisor Name: _____________________ Signature:_____________________________________


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2.12.2 PERFORMANCE REVIEW - COMMUNITY SUPPORT WORKER

Employee’s Name: ___________________ Date completed: ______________________

Facilitated by: _________________ Next review date: _____________________

Reason for review: probationary period (520 hrs) trial period annual

The Community Support Worker job description (Practice and Procedures Manual, Sec4) has been utilized for

the purpose of this performance planning. Other information has been gathered from performance indicators

documented in “Occupational Standards of Competence, Services for Community Living.”

PROCEDURE:

The Performance Review is a tool used to discuss current strengths, desired changes or training needs, and

progress towards goals. Performance Reviews shall not be used as disciplinary action.

PRIOR TO REVIEW:

1. Employee will be notified at least one week in advance of date and time of Performance Review. At this

time the employee will be:

Given the option of completing a self-evaluation (Section One) to bring to the Review for

discussion purposes

Informed of the location in the Practise and Procedure Manual of the ‘Performance Planning and

Review’ Form in order that the employee has the opportunity to review it.

FOLLOWING REVIEW:

1. Employee and Supervisor are to sign and date the Performance Review;

2. Supervisor is responsible to ensure the employee receives a copy of the completed review;

3. Original Performance Review will be submitted to the Executive Director for his information then

placed in the employee’s personnel file;

PERFORMANCE REVIEW WILL BE COMPLETED AS FOLLOWS:

Casual employees: 520 hrs annually

Trial Period employees: before 3 months

Permanent employees: annually


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SECTION ONE - COMMUNITY SUPPORT WORKER - SUMMARY OF PRINCIPAL

STRENGTHS

*Employees to complete prior to review meeting and bring to meeting for discussion and for attachment to

completed performance review.

1. For those employees who had a previous performance review, how did you do?

Comments:

Please discuss and determine 5 principal strengths or talents you have as an employee of CCS. This could

include specific activities or accomplishments of which you are particularly proud.

1.

2.

3.

4.

5.

What aspect of the job do you find most rewarding?

What aspect of the job do you find most challenging?

Is there any way in which CCS or your supervisor can help you do your job better?


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SECTION TWO COMMUNITY SUPPORT WORKER - PERFORMANCE REVIEW

Competencies: Please circle the performance rating, using the specific competencies as guidelines.

Skill and Knowledge Competencies are measured as follows:

E – Exceeds expectations; excels at duties outlined in job description

M – Meets expectations; completes duties as outlined in job description

R – Requires support to meet expectations; supervisor and employee will need to discuss and set goals for

success in Section One

U – Unable to asses (due to long-term approved absences or lack of opportunity for employee to demonstrate

this skill)

*Please note: ‘K’ indicates that the competency includes additional duties for those employees who are

key workers.

Self Rating: Final Rating:

1. Promote and support individual rights and self determination

a. Promote and defend individual rights: E M R U

Advocacy efforts reflect needs and preferences of individuals K

Consults additional resources or expertise if required, including

personal support networks K

Provides personal information to others only with informed consent

Promotes independence and self determination

b. Promote respectful treatment of individuals: E M R U

Uses respectful and non-labeling language in written, spoken, and

non-verbal communications with and about individuals

Models, encourages and supports others in respectful interactions

with individuals

Respects and observes principals of ownership and privacy

c. Promote and defend individual lifestyle choices: E M R U

Respects and acknowledges individuals’ personal values, beliefs, and

lifestyle choices in all interactions and activities

d. Facilitate informed decision-making: E M R U

Consistently offers choices to all individuals K

Supports individuals to identify possible benefits, consequences or

risks associated with choices in an accurate, unbiased and timely

fashion K

Provides information in a manner consistent with individual

communication strategies

Supports choices or decisions made by individuals K

e. Facilitate the use of inclusive communication strategies: E M R U

Participates in assessing and identifying communication needs and

choices

Utilizes augmentative communication strategies or adaptive

technologies, as required

Comments:


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2. Promote and enhance personal relationships and support

networks

a. Facilitate meaningful involvement of friends and family: E M R U

Supports individuals to communicate and interact on a regular basis

with family and friends K

Appropriately observes and assists in planning and implementation of

significant life or family events, as required (birthdays, Christmas,

Mother’s Day, vacation planning, grad, etc) K

b. Facilitate opportunities for the development of personal relationships: E M R U

Identifies and provides opportunities for individuals to have regular

contact with people of their choosing

Supports individual choices and preferences for relationships and

helps individual develop strategies for successful relationships. K

c. Promote and facilitate the relationship between individuals and service

providers:

E M R U

Supports individuals in making informed decisions, and

communicates needs and preferences to the service provider K

Comments:

3. Contribute to the development and implementation of

personalized plans

a. Participates in the assessment of individual service and support needs:

K

E M R U

Supports individuals to identify service and support needs in

collaboration with their personal support system. K

b. Participates in the development of personalized plans E M R U

Attends planning meetings or provides written input K

c. Participates in the implementation of personalized plans E M R U

Assists in identifying resources needed K

Supports individual to achieve stated goals and outcomes K

Maintains, and updates regularly, documentation related to the plan

(progress reports, outcomes, daily logging etc.) K

Comments:


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4. Promote the health, safety and well-being of individuals a. Support individuals to meet their physical, emotional and personal care

needs

E M R U

i.Medications E M R U

Administers (or assists with self administration) medications

according to CVACL procedures

Demonstrates knowledge of medications in use K

Is familiar with medication error and PRN procedures

Completes medication documentation in an accurate and timely

manner

ii.Health Care E M R U

Stays up-to-date on Health Care Plans and other assessments K

Assesses and adapts the environment to meet individual health needs

Supports individuals to maintain a regular health care routine K

Provides personal support respectfully and effectively, honouring

values of the individual

Communicates observations/concerns with team and health

professionals. K

Maintains required ‘health and wellness’ records and documents

Operates assistive devices safely (lifts, van tie-downs, wheelchairs,

etc)

Utilizes safe lifting and transferring techniques

iii.Behavioural Support E M R U

Use positive language when talking about an individual’s behaviour

Contributes to the development, evaluation, and implementation of

the Behaviour Plan K

Interprets antecedents and intervenes effectively before the behaviour

occurs (i.e. Attempts to restructure the environment or environmental

events which are believed to be triggering the behavior)

Demonstrates skilled use of re-direction, where appropriate and as

outlined in a Behaviour Plan i.e. follows validation, is constructive,

non-punitive, timely etc.

Coaches and mentors new employees regarding approaches to

challenging behaviors

b. Contribute to strategies for preventing and responding to abuse E M R U

Informs individuals about their personal rights and forms of abuse

K

Supports individuals to develop strategies for self-protection K

c. Promote and support informed decision-making about health care

services and supports

E M R U

Identifies, documents, and communicates individual preferences and

choices about health care, and identifies barriers, to health care

professionals and personal support networks K


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d. Establish and maintain a safe and healthy physical environment E M R U

Consistently meets occupational health and safety standards in day-

to-day practise

Maintains the physical environment according to schedule and

assigned duties i.e. indoor/outdoor maintenance, inventory, etc

Promptly reports all equipment deficiencies, problems, and

irregularities to appropriate person

Comments:

5. Advocate for inclusion and meaningful contributions by

individuals in their communities

a. Facilitate opportunities for individuals to contribute to the community. E M R U

Supports individuals to participate in community events according to

their interests K

Provides individuals with information to assist in choosing preferred

activities K

Identifies barriers to participation and helps to develop strategies for

improvement K

b. Facilitate access to community-based resources, supports and service. E M R U

Develops and implements strategies (may include use of adaptations

and technology) to improve and increase individual access to

community services and resources. K

Comments:

6. Promote professional and organizational effectiveness and

accountability

a. Communicate with team members to enhance team and individual

performance:

E M R U

Is timely and relevant in communication with team members

Provides leadership and guidance to new employees and students

b. Cooperate with team members to solve problems, resolve conflicts and

make decisions:

E M R U

Identifies and offers constructive and feasible solutions to problems

Uses effective conflict resolution strategies to resolve differences

Listens, and responds respectfully to, expressed differences in views


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c. Maintain records and documentation related to the individual and the

organization

E M R U

Clearly writes and completes required records according to assigned

time lines K

Maintains confidentiality of documentation

Comments:

7. Develop self to meet current and future needs

a. Participate in ongoing personal and professional development E M R U

Regularly assesses own performance and identifies and implements

strategies for improvement

Participates in training and education, as available, to enhance ability

to respond to change

Comments:

OVERALL PERFORMANCE (please one):

___ Exceeds job requirements and expectations

___ Meets job requirements and expectations

___Minimally meets job requirements and expectations

___Does not meet job requirements or expectations

Comments:


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SECTION THREE COMMUNITY SUPPORT WORKER - SUMMARY OF PRINCIPAL GOALS

Review the “Competencies” and identify where goals are required or desired (NI on the Performance Review).

Prioritize a maximum of 5 major goals. Write the goals below along with a mutual plan of how those goals will

be achieved. Include a time frame. Plan to review progress towards goals with your supervisor throughout the

year.

1. Goal:

Action Plan:

Time frame:

2. Goal:

Action Plan:

Time frame:

3. Goal:

Action Plan:

Time Frame:

4. Goal:

Action Plan:

Time Frame:

5. Goal:

Action Plan:

Time Frame:

Additional Comments:

__________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________

I agree/disagree (please circle one) with this performance review.

I agree to make a commitment to complete the action plans as stated above.

_________________________________ ______________________________

Signature of Employee Signature of Supervisor


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SECTION FOUR COMMUNITY SUPPORT WORKER - PROFESSIONAL DEVELOPMENT

RECOMMENDATIONS

Please determine whether this employee would benefit from any of the following workshops and determine

whether this is high or low priority (Use ‘H’ or ‘L’ to indicate). High priority would be skills or knowledge that

have been identified as NI in the Review process; low priority would be to gain new skills or for personal

development. All professional development is subject to administrative approval. The following is for

organizational planning only:

Non-violent Crisis Intervention

Medication Administration Review

Lifts and Transfers

Individualized Service Planning

Community Living Values (please specify) _________________

FOIPOPA

Computer Training (please specify)_____________

Management Training (please specify) _________________

Sensory Integration

Aging

Accessing Community

Specific health issues (please specify) _______________________

Examples: Oral health, Autism, FASD, Dysphagia, Seizure disorders, Down’s syndrome, etc.

Specific mental health issues (please specify) _________________________

Examples: Obsessive Compulsive Disorder, Dual Diagnosis,

Range of Motion

Cultural Awareness

Program Design and Development

Recreation/Leisure therapies (please specify)________________________

Examples: Art, Drama, Music, Recreation Integration, Dance etc.

Other:_______________________________________

Name of Employee: ____________________________ Date: ___________________


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2.12.3 CLEMENTS CENTRE - PERFORMANCE REVIEW

The performance review will ensure each employee’s work supports the organization’s goals. The annual review looks at

the accomplishments of the past year and sets goals for the coming year. Employees are encouraged to meet with their

manager every six months to discuss their progress in achieving their goals.

Each employee is to complete the review and give it to their manager for their comments. The employee has the

opportunity to agree or disagree with the manager’s comments. The review is then submitted to accounting for inclusion

in the employee’s personnel file.

Goal(s) from my last performance review:

Accomplishments to meet that goal(s):

Goal(s) for the coming year:

Training to assist in meeting the goal(s) for the coming year:

excellent average could be better

1. I met the performance goals identified in my previous review.

Comments.

2. I carry out the duties outlined in my job description.

Comments.

3. I maintain the necessary professional certifications.

Comments.

4. I understand the regulations, policies, procedures and

other factors affecting this job.

Comments.


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excellent average could be

better

5. My workload is within industry standards and is

completed in a thorough, and timely fashion.

Comments.

6. I use judgement and make sound decisions in a timely manner.

Comments.

7. I communicate effectively in both written and spoken manner;

I participate in one-on-one and group discussion.

Comments.

8. I plan and organize effectively; set priorities, meet deadlines,

establish and follow plans.

Comments.

9. I have initiative; I’m a self starter who seeks solutions.

Comments.

10. I am adaptable. I adjust to changes in work assignments,

objectives, goals, new procedures.

Comments.

11. I have the ability to get along with a variety of personality types;

I promote understanding; establish good rapport.

Comments.

12. I attend work on a regular basis; punctual; appropriate use of sick time.

Comments.


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Manager’s Comments. After reviewing the employee’s self performance review, I have the following feedback

and agree to support these goals and training.

1. Comments.

2. Goals for the coming year

3. Training for the coming year

If first review, pass probation yes no or extend probation period to ___________ (date).

Manager’s Signature _____________________________ Date: _________________________

I agree with this review yes no

Comments.

Employee’s Signature _____________________________ Date: ________________________


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2.12.4 PERFORMANCE REVIEW - MANAGER FEEDBACK FROM DIRECT REPORTING STAFF

Name of Manager: ______________________________

1. The strategic plan calls for an environment where employees feel valued and supported.

Does the manager support a team environment that

promotes people’s ability to work productively together? yes no

Comments:

2. The strategic plan calls for the development and delivery of services that are responsive to the clients’

needs.

Does the manager’s performance contribute to the development

and delivery of responsive services? yes no

Comments:

3. Any other comments?


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2.12.5 PERFORMANCE REVIEW - EXECUTIVE DIRECTOR FEEDBACK FROM BOARD

1. Is the executive director making progress towards meeting

the mission and vision? yes no

Comments:

2. Is the executive director making progress in meeting

the objectives outlined in the strategic plan? yes no

3. Review the Board policies which state our expectations for executive director performance in such areas

as the general limits on authority, treatment of employees, financial management, and the overall

information provided to the Board.

Comment on the executive director’s compliance with these policies. If you are not satisfied, provide

examples and indicate your reasons.

4. Any other comments?


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2.12.6 PERFORMANCE REVIEW - PEER REVIEW

Employee Name _________________________________________________

Position_________________________________________________________

Purpose of Evaluation _________________________________ Date_______________________

Completion and Submission Process: 1. Complete the below areas using the following ratings: A: Above standard; C: Competent; M:

Marginal; I: Inadequate; U: Unable to Assess

2. Place the Review in a sealed envelope and address it to “Executive Director: in Confidence”

3. The Executive Director will integrate your feedback into the final evaluation and then destroy

the Review form you have completed. Your name will remain confidential to the Ex. Director.

Unsigned evaluations will not be considered.

Area Rating

1. Job Knowledge. Measures understanding of the job, including regulations & policies. _____

2. Application of Duties. Measures thoroughness, application of

knowledge, need for check or review. _____

3. Quantity of Work. Measures volume and output of work. _____

4. Judgment. Measures sound decision making ability without delay. _____

5. Oral and Written Communication. Measures effective of gaining understanding with these mediums. _____

6. Planning and Organization. Measures efficient application of duties, including clear goal setting

effective use of time, ability to task focus and follow through. _____

7. Initiative. Measures energy, drive and enthusiasm. _____

8. Adaptability. Measures flexibility, ability to adjust to change _____

9. Ability to Deal with Others. Measures stress tolerance and professionalism. _____

10. Attendance. Measures punctuality, appropriate use of sick time and consistent

Attendance. _____

Describe any significant areas needing improvement_______________________________________

_________________________________________________________________________________

Describe any significant accomplishments _______________________________________________

________________________________________________________________________________

Employee ______________________________________ Date________________________

CLEMENTS CENTRE

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2.13 PROFESSIONAL DEVELOPMENT REQUEST AND RECORD

Completed for each training session - record to be kept in the Employee Personnel file.

Name _______________________________________ Date ______________________

CCS Program _______________________________

Title of Training

________________________________________________________________

Start Date of Training __________________________End Date of Training _____________

Reason for Training __________________________________________________________

___________________________________________________________________________

Is the training mandatory yes no

How will the training benefit the clients, organization, and community?

___________________________________________________________________________

___________________________________________________________________________

How will you demonstrate that you have learned?

___________________________________________________________________________

___________________________________________________________________________

How will you share your learning with other employees, clients, Board members? When will

this take place?_____________________________________________________________

___________________________________________________________________________

Is staffing relief required? ________If so, for how Long?______________________

Are you requesting;

time off with pay, if so how many hours/days _________ time off without pay

employer paid course/registration fees at a cost of _____________

employee paid course/registration fees at a cost of _____________

employer to pay meals, accommodation, travel at a cost of _________

employee to pay meals, accommodation, travel at a cost of ____________

Recommended (circle): yes no Supervisor

________________________________ Approved (circle) yes no Administration _____________________________

Follow up

Was the training relevant?

_______________________________________________________________

How has the training affected your ability to do your job?

______________________________________

__________________________________________________________________________________

CLEMENTS CENTRE

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2.14 VACATION REQUEST

NAME:

_____________________________________________________________________

Jan 1 – Apr 30 requests due by November 1

May 1 – Dec 31 requests due by March 1

Please keep request in the time frames above

FIRST CHOICE

Dates: ________________________________ Approved: __________________

# of paid days/hours requested_________________ Date:

________________________

AND/ OR (please circle one) SECOND CHOICE

Dates: ________________________________ Approved: __________________

# of paid days/hours requested________________ Date: _____________________

AND/ OR (please circle one) THIRD CHOICE

Date: _____________________________________ Approved: _________________

# of paid days/hours requested: _______________ Date: _____________________

Total Number of Days/Hours Requested: _________________________________________

Employee Signature __________________________ Date: _____________________

Comments:_________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Administration use only: Number of paid vacation days/hours left until Dec. 31 ________

Copy to Admin Copy to Scheduler Copy to Employer

CLEMENTS CENTRE

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2.15 Rental Agreement for Clements Centre at 5856 Clements Street, Duncan

cafeteria $100 full day / $50 half day (4 hours or less) + HST

kitchen $100 full day / $50 half day (4 hours or less) + HST

cafeteria and kitchen $150 + HST

activity room $100 full day / $50 half day (4 hours or less) + HST

fee waived __________________________ must be approved by Executive

Director signature Program Director, Director

of Finance

Rental dates _____________ of ____________ 201_ between the hours of _____ and

_____.

Renter ____________________________

____________________________________ Name (business, agency, or person) representative’s name if a business or agency

__________________ __________________

__________________ Street city telephone

The following are the conditions to which the Renter agrees:

1. Emergency. Renters are responsible for familiarizing themselves with the

entrances/exits.

2. Janitorial. Renter is responsible for clean-up or a janitorial fee of $100 will be charged.

3. After normal business hours, should no Clements employee be in the building, the renter

is responsible for insuring: lights off; alarm on; building locked.

4. Keys must be returned within 24 hours. Lost key = $250.

5. Losses and damages. Renter is responsible for losses and damages arising from the

rental.

6. Liability. Renter assumes all risks associated with renting the facility and will hold

Clements Centre Society harmless for any and all liability arising from my rental.

7. Kitchen supplies are NOT included. This includes coffee, all food supplies, and all

expendable supplies such as plastic wrap, aluminum foil, paper towels, etc.

8. Kitchen dishes, pots, pans, utensils, etc. are NOT to be taken from the building.

I have read and agree to the above conditions.

________________________________________

____________________________________

Name (print) signature

CLEMENTS CENTRE

Section 2 – Forms

Office Use

Identification of renter verified pre-payment received receipt issued 2.16 COMPLAINT REPORT

Date of complaint: _________________Complaint received by: ___________________

Complainant: __________________________________Phone #: __________________

Section 1

Complaint/Concern: Health and Safety Personnel Other

_______________________________________________________________________

_______________________________________________________________________

Immediate Action Taken: _________________________________________________

_______________________________________________________________________

Section 2

Further Action Required: __________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Supervisor’s Follow-up: ___________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Management Action Required: Yes No

Supervisor’s Signature: _____________________________Date: _________________

Section 3

Management Follow-up (if applicable): _______________________________________

_______________________________________________________________________

Signature of ED (or designate):________________________Date: _________________

Attachments? Yes No

CLEMENTS CENTRE

Section 2 – Forms

2.17 Media Consent Clements Centre Society’s adult services charisma is captured through pictures of our participants both at the day program and in the community. CCS is committed to using these pictures in a way that is respectful to you and consistent with our mission statement: “we support citizens of the Cowichan Valley to participate meaningfully in all aspects of community life”. External Publication Clements Centre Society requires your permission to share photos for different media. Such media (on paper or the computer) may include our website, lobby photos, display boards, invitations, brochures, magazines, slide shows, videos, and newspapers. First names and last name initials may accompany the pictures. Please indicate your preference by checking ONE of the boxes below and signing at the end of this document.

Yes, I grant CCS the right to use, publish and display pictures of myself as described.

No, I do not consent to having pictures of myself published or displayed as described.

Participant Name: ______________________________________ _____________________________________ ________________________ Participant Signature Date _____________________________________ ________________________ Representative’s Signature (if applicable) Date

_____________________________________ ________________________ Staff Signature Date I have explained this form to the best of my ability.

CLEMENTS CENTRE

Section 2 – Forms

2.18 RELEASE OF CLIENT INFORMATION (ALSO SEE CONFIDENTIALITY) With your consent CCS will only release information:

that we wrote

to the people who you choose

All requests shall comply with the Freedom of Information and Protection of Privacy Act. In

order to release information, the following form must be completed.

Consent to the Release of Information

I, ___________________________________ Birth date:___________________

give my consent for CCS staff to share the following information:

(Type of report or specific information)

only to:

(Agency and/or person who will receive the information)

Effective from: (date) ____________________ to _________________________

Staff Acknowledgement: I have explained this form and its meaning to the best of my ability:

Staff signature: _____________________________ Date: ________________

_____________________________ ______________________________ Client signature or Representative’s signature Date: _____________________________________

clements centre society section 2 - forms personnel formsclements centre society section 2 - forms...

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