Attachment_3_-_Monthly_Report_Template.pdf

Attachment 3 – Monthly Report Template

Center for Tobacco Products

State/Territory: __________________________________

Agency/Department/Contractor:____________________

Contract Number: _________________ Month: ______

Period Covered: ______________ to _______________

Program Coordinator: ________________________________

Prepared By: ________________________________________

Monthly Report for

FDA Tobacco Compliance Check Inspection Program

State/Territory: ____________ Agency/Department: ____________________________

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Program Overview

Retail Outlets Month 1 Month 2 Month 3 Month 4 Total number of Retail Establishments in State Number eliminated by pre-screening1 Total eligible for inspection after pre-screening Total number of tobacco retail establishments assigned Total number of FFA assignments Total number of deliveries to retailers

As of _________, the retail outlet information contained in FDA’s TIMS contains the most current retail outlet information possessed by the Contractor.

Training Updates this Month Name Initial Training

Date Last Training

Update

Follow-up Questions from FDA2 Month 1 Month 2 Month 3 Month 4 Total answered Total pending

Reason for pending questions:

1 Prescreening is identifying which retail outlets are closed or ineligible for inspection prior to an inspector attempting to conduct an inspection at the retail outlet.

2 A Follow-up Question from FDA is an inquiry from the jurisdiction’s trainer or COR regarding a specific inspection asking for a written response from the jurisdiction.

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Program Participants Added this Month Name Start Date Initial Training

Date

Program Participants Removed this Month Name Last Official Day

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Retail Inspection Coverage Plan

Briefly describe the retail inspection coverage plan3 used during this month:

Briefly describe the retail inspection coverage plan to be used during the next month:

3 Retail inspection coverage plans outline how specific geographical areas of the state are divided and assigned for inspections, how each type of inspection is assigned, and the expected number of inspections to be completed.

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Program Coordination4

Briefly describe how the Contractor coordinated with the State/Territory Synar Program during this month:

Briefly describe how the Contractor plans to coordinate with the State/Territory’s Synar Program during the next month:

Briefly describe how the Contractor coordinated with any other non-FDA tobacco control program(s) in the state, territory, or tribal area during this month:

Briefly describe how the Contractor plans to coordinate with any other non-FDA tobacco control program(s) in the state territory, or tribal area during the next month:

4 If the Contractor does not coordinate inspections and/or results with Synar or state or local enforcement, simply answer N/A for the first 2 questions.

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Youth Coverage

Describe how retailers in areas that are in close proximity to where there is a high concentration of youth (e.g., schools, recreation centers, etc.) were inspected in this month.

Describe how retailers in areas that are in close proximity to where there is a high concentration of youth (e.g., schools, recreational centers, etc.), will be inspected in the next month:

Minority Coverage Describe how retailers in racial and ethnic minority communities were covered in this month.

Describe how retailers in racial and ethnic minority communities will be covered in the next month:

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Media Coverage month 1 month 2 month 3 month 4

Number of Media Coverage Events, Contact, and/or Inquiries, if any

Describe any media contact and/or inquiries during this month, including the points of contact:

Please provide name of the person contacted at FDA and the date/time this person was informed of the media contact/inquiry:

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Feedback

Describe your experiences regarding the use of handheld devices and other hardware, hardcopy forms, TIMS, and the online compliance check inspection process:

Feedback regarding the FDA program in general:

Contract Number: __________________ Month: ______ Period Covered: ________ to _________

Access to Government Property

In accordance with the Control of Property Section of the Contract (G.7), all accountable property should be reported annually. While not required to use the HHS Form 565, we have attached the form as a guide that you may use to track accountable property. Accountable property is nonexpendable personal property with an acquisition cost of $5,000 or more, and with a useful life of two years or more and sensitive items (regardless of acquisition value). Examples of sensitive items include computers, smartphones, and cameras. For a full list of sensitive items, please see the Sensitive Items Policy for Personal Property and Equipment attached below.

Sensitive Items Policy.pdf

HHS Form 565.pdf

Describe your program for the protection, preservation and maintenance of all Government property, procedures to educate your employees concerning individual responsibilities for Government property, and efforts to monitor and assess your property control system:

If Contractor disposed of any equipment or Government Property, describe the means by which this was done and who was consulted prior to such action: