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Attachment #4, 9.01 1 of 9

Operations Monitoring Forms Internal and External Monitoring

Clinic Observation

Certification and Eligibility – Observation of Intake Process

Categories of Participants Observed: (Use tally marks to show how many participants were seen.) P B N I C

During clinic observation, are rights and responsibilities verbally explained and Participant Agreement electronically signed? Is the signature legible and belonging to the proper parent/guardian or caretaker of the family?

Is correct documentation used to verify income, identification and residency?

Is racial and/or ethnic data collected and properly documented in the computer?

Are applicants who receive SNAP, AFDC, and/or Medicaid certified as adjunctively eligible?

Is applicant/participant physically present during certification?

Are infants and children screened for immunization status?

Are referrals to other agencies appropriate and properly documented during clinic observation?

The following documents are scanned into the participant’s record if applicable: