D.2 ATTACHMENT 2 QUALITY ASSURANCE MONITORING FORM.docx

This file is a sample Quality Assurance Monitoring Form template designed to document and track service provider performance compliance. The form provides a standardized structure for conducting surveillance activities across various service or standard categories during defined survey periods. Organizations can select from multiple surveillance methodologies including random sampling, 100% inspection, periodic inspection, or customer complaint-based reviews, with flexibility to establish monitoring frequency at monthly, quarterly, or as-needed intervals.

The form captures key performance metrics by documenting the percentage of items sampled during the survey period and analyzing results against established standards. The preparer must record the observed service provider performance measurement rate and indicate whether performance meets or does not meet established standards, with space provided for a narrative summary of performance observations during the survey period. The form concludes with signature and date fields for the preparer responsible for completing the quality assurance review. This is a template document with no specific products, services, pricing, or contractual obligations detailed.