SOP 107.07-att-1: Peer Evaluator Application_Agreement to QA

SOP 107.07
Attachment 1

5/2/22
# Peer Evaluator Application/Agreement to QA

Name: _________________________________ Facility/Work Site: ________________

Contact Number: _____________________Position/Job Title: _____________________

Reentry and Cognitive Programs

Name: _____________________________________________

How long have you facilitated this program? ___________________________________

Do you have any experience facilitating any other programs (Yes/No)? ______________
If yes, please list the programs taught and the length of time facilitated:
________________________________________________________________________
________________________________________________________________________

Do you have any experience supervising any other employees (Yes/No)? _____________
If yes, please list your management experience? _________________________________
________________________________________________________________________

How would being a Peer Evaluator affect your current job responsibilities?
________________________________________________________________________
________________________________________________________________________

Are you able to use a state vehicle for peer review purposes (Yes/No)? ______________

Are you able to conduct one QA every three months at another site (Yes/No)? ________

Describe your typical work schedule:

Monday: ________________Tuesday: ________________Wednesday: ______________
Thursday: _______________Friday: ________________

Briefly describe why you would like to become a Peer Evaluator:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

_________________________________ _____________
Applicant's Signature Date

_________________________________ _____________
Approving Supervisor's Signature Date

Retention Schedule: Upon completion, this form should be kept on file, for review by the Office of Reentry Service,
for one (1) year.