MonitoringReport(Template).doc

Monitoring Report (Template) Provider Name: Report Date: Provider Mailing Address: Review Period: , Program Name / Location: / , , , Review Date(s): Circuit(s): On-site Review Desk Review County(s): Contract/Grant #: Contract/Grant Start Date: Total Contract/Grant Dollar Amount: Contract/Grant End Date: Type of Service: Program/Provider Contact: Contract Manager: Monitoring Member(s): Provider Attendee(s): Executive Summary: Summary Rating (Select one and include a brief narrative): Based on the information reviewed, no deficiencies about provider compliance and performance were identified. Based on the information reviewed, deficiencies about provider compliance or performance were identified. (If this statement is selected, provide the number and a brief description of the deficiencies identified.) Scope/Monitoring Purpose: Background:  Documents Reviewed: Sample Size/Description of File: / # Files Reviewed: Findings/Deficiencies: Administrative Finding/Deficiency CAP Required Deficiency Type #1 Yes No Major Minor #2 Yes No Major Minor Programmatic Finding/Deficiency CAP Required Deficiency Type #3 Yes No Major Minor #4 Yes No Major Minor Observations/Comments: Summary:  Approval History: Prepared By: Date: / Print and Sign Title Reviewed/Approved By: Date: / Print and Sign Title Acceptance/receipt of monitoring report does not mean the provider wholly agrees with all findings/comments contained herein. 1