Feedback Form: Coaching Workshop

TeamSTEPPS® Long-Term Care Version, Module 9

The Long-Term Care version of TeamSTEPPS adapts the core concepts of the TeamSTEPPS program to reflect the environment of nursing homes and other other long-term care settings such as assisted living and continuing care retirement communities. The examples, discussions, and exercises below are tailored to the long-term care environment.


While observing the scripted coaching role play, use this form to document the demonstrated competencies of the designated coach. The coach works through the designated issue with the team member, the team member acts out the particular scenario, and the observer watches the interaction and notes on the coaching observation form which competencies the coach exhibits and does not exhibit.

Coaching Criteria Demonstrated
Yes No
Communication Instructions      
Providing Feedback      
Listening for Understanding      
Performance Improvement
Setting Performance Goals      
Rewarding Improvement      
Dealing With Failure      
Assessing Strength and Weaknesses      
Building Rapport and Trust      
Motivating Others      
Working With Personal Issues      
Confronting Difficult Situations      
Responding to Requests      
Following Through      
Page last reviewed November 2012
Page originally created November 2012
Internet Citation: Feedback Form: Coaching Workshop. Content last reviewed November 2012. Agency for Healthcare Research and Quality, Rockville, MD.