Attachment G Quality Assurance Monitoring Form.pdf

QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check One):

Random Sampling Periodic Inspection 100% Inspection Customer Complaint

LEVEL OF SURVEILLANCE (Check One):

Monthly Quarterly Annually As needed

BARCODES SAMPLED:

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: %

ANALYSIS OF RESULTS:

Service Provider’s Name:

Observed Service Provider Performance Measurement Rate: %

Service Provider’s Performance (Check One): Meets Standards Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY (Print): DATE:

PREPARED BY (Sign):

Attachment 6A_QASP Quality Assurance Monitoring Form

As of: 9/16/2014

Attachment 6A_QASP Quality Assurance Monitoring Form

As of: 9/16/2014