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U.S. Department of Health and Human Services

Inspections, Compliance, Enforcement, and Criminal Investigations

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Appendix I Contract Inspection Audit Program Evaluation Form

ORA FIELD MANAGEMENT DIRECTIVE No. 76
Appendix I

Subject:
State Contracts-Evaluation of Inspectional Performance
Area:
State Program Management
Date:
8/22/6 Revised

Printer Friendly Version: Word  Size 35 kb


Appendix I

Contract Inspection Audit Program Evaluation Form

 

District office: ________________________________________ Contact person: __________________

 

State agency: _________________________________________ Contact person: __________________

 

For contract performance period: _______________________________

 

 

Implementation phase (circle one): Phase II     Phase III

Complete this section for Phases II and III:

Total number of contract inspections ____
Total number of required audits ____
Number of training audits for State inspectors ____
Number of verification audits for State inspectors ____
Number of contract audits completed by District office ____
Number of contract audits completed by State agency ____


Complete this section for Phase III:

Number of verification audits of State auditors [1] ____
Number of audits rated as acceptable ____
Number of audits rated as needs improvement ____

 

 

Complete this section for Phases II and III:

 

  1. Recommendations (record strengths/weaknesses):



  2. Recommend continuation of contract audit option (circle one): Yes     No

  3. Evaluation was discussed between District office and State agency on: ____________(date)

  4. Names and titles of persons who participated in evaluation:

    _______________________________ ____________________________________

    _______________________________ ____________________________________

    _______________________________ ____________________________________

Endnote:

 [1] Phase III verification audits of State auditors conducted by the District office for the 24-month evaluation of the State’s implementation of the audit program may be counted against the total number of audits.

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