AttB-Sample Quality Assurance Monitoring Form.pdf

This document is a Quality Assurance Monitoring Form template designed to track and evaluate service provider performance. The form provides a structured method for conducting performance surveillance through various methods including random sampling, 100% inspection, periodic inspection, or customer complaint tracking. The form allows for different surveillance levels (monthly, quarterly, or as needed) and requires documenting the percentage of items sampled, observed service provider performance measurement rate, and an overall performance assessment of whether the service provider meets or does not meet established standards. The form includes sections for CLIN (Contract Line Item Number), survey period, surveillance method, percentage of items sampled, performance analysis, and a narrative description of performance, with space for the preparer's signature and date.