Fillable Louisiana State Board of Social Work Examiners - Plan of Supervision

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Louisiana State Board of Social Work Examiners - Plan of Supervision

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Louisiana State Board of Social Work Examiners

BROWSE LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS FORMS

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Plan of Supervision
Supervisee: _________________________________ Supervisor: _______________________________________________
INSTRUCTIONS: Formulate at least (1) goal, activity, and outcome for each of the following areas of practice. It should be noted that the submitted plan is the
base from which the supervisee begins the supervisory process. As the supervisee achieves various goals, new goals can be added and evaluated throughout the
designated hours of the supervisory process.
GOAL(S):
…broad general statements that
describe broad learning outcomes and
concepts in general terms.
ACTIVITY(IES):
…brief, clear statements that describe
the desired learning outcomes, the
specific skills, values, and attitudes
that reflect broader goals. It is a clear
and measurable target. Intended
results.
OUTCOME(S):
…evidenced based measures the
LCSW-BACS uses to determine
whether or not the LMSWs have met
their goals. Achieved Results.
Formula
Supervisee will
(action/change word) + (content area
to change/move)
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act.
Supervisee will
(action word) + (content area to
change or move) + by (activity to be
completed) + (how much/many) + (by
when).
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act by reading the Social
Work Practice Act and indicating
improvement on the Pre/Post
Learning Plan Grid within a 30 day
period.
Supervisee will have achieved this
goal…
As measured by…
Supervisee indicates increased
knowledge on the Pre/Post Learning
Plan Grid.
As evidenced by…
Social Work Practice Act has been
read
Social Work Practice Act was read
within the time projected
…so noted on the plan and in the
supervision file.
Ethical Standards of Practice
Relationships with Clients
GOAL(S):
…broad general statements that
describe broad learning outcomes and
concepts in general terms.
ACTIVITY(IES):
…brief, clear statements that describe
the desired learning outcomes, the
specific skills, values, and attitudes
that reflect broader goals. It is a clear
and measurable target. Intended
results.
OUTCOME(S):
…evidenced based measures the
LCSW-BACS uses to determine
whether or not the LMSWs have met
their goals. Achieved Results.
Formula
Supervisee will
(action/change word) + (content area
to change/move)
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act.
Supervisee will
(action word) + (content area to
change or move) + by (activity to be
completed) + (how much/many) + (by
when).
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act by reading the Social
Work Practice Act and indicating
improvement on the Pre/Post
Learning Plan Grid within a 30 day
period.
Supervisee will have achieved this
goal…
As measured by…
Supervisee indicates increased
knowledge on the Pre/Post Learning
Plan Grid.
As evidenced by…
Social Work Practice Act has been
read
Social Work Practice Act was read
within the time projected
…so noted on the plan and in the
supervision file.
Relationships with Other
Professionals, Groups, and
Communities
Cultural Competence and Social
Diversity
Intervention Process
GOAL(S):
…broad general statements that
describe broad learning outcomes and
concepts in general terms.
ACTIVITY(IES):
…brief, clear statements that describe
the desired learning outcomes, the
specific skills, values, and attitudes
that reflect broader goals. It is a clear
and measurable target. Intended
results.
OUTCOME(S):
…evidenced based measures the
LCSW-BACS uses to determine
whether or not the LMSWs have met
their goals. Achieved Results.
Formula
Supervisee will
(action/change word) + (content area
to change/move)
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act.
Supervisee will
(action word) + (content area to
change or move) + by (activity to be
completed) + (how much/many) + (by
when).
Ex: Supervisee will increase
knowledge about the Social Work
Practice Act by reading the Social
Work Practice Act and indicating
improvement on the Pre/Post
Learning Plan Grid within a 30 day
period.
Supervisee will have achieved this
goal…
As measured by…
Supervisee indicates increased
knowledge on the Pre/Post Learning
Plan Grid.
As evidenced by…
Social Work Practice Act has been
read
Social Work Practice Act was read
within the time projected
…so noted on the plan and in the
supervision file.
Application of Theory
Oral Communication
Documentation
Self-Evaluation
Continuing Education
IMPORTANT:
This form is to be received within 60 days of the first supervision session. The original shall be mailed to the Louisiana State Board of Social Work Examiners and
a copy shall be maintained in the LMSW’s file.
Changes in supervision arrangements, such as employment change of the supervisee, change in LCSW-BACS supervisor, or substantial change in job description
require a new Supervision Agreement and updated Plan of Supervision. This documentation shall be received by the board within 60 days of the change.
The Supervision Agreement/Plan of Supervision will be reviewed and revisions may be required. Revisions shall be submitted to the board office within 30 days
of receipt by the supervisor. A letter confirming board approval and the beginning date of supervision credit will be sent.
This form is to be submitted with a completed “Employment Verification”.
____________________________________________________________ _____________________________________
Supervisee’s Signature Date
____________________________________________________________ _____________________________________
Supervisor’s Signature (LCSW-BACS) Date
____________________________________________________________ _____________________________________
*Agency Supervisor’s Signature Date
Revised 2017
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Louisiana State Board of Social Work Examiners - Plan of Supervision

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Completed 24 May 2020

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