ࡱ> @ GXbjbjצצ c *0,,,8ktk:,..../'0Ls0(8]::::::$;R>&:]0//00&:..:2220..8208222.m B,0^23:0:2>1`>2>200200000&:&:o2CONTRACT MONITORING QUESTIONNAIRE UNIT RATE CONTRACT Department of Human Services Contractor Name FORMTEXT      Contract # FORMTEXT       FORMTEXT     FORMTEXT      1.Please provide a brief description of the services you provide under this contract. FORMTEXT      2.Please describe your record keeping system for documenting services provided. FORMTEXT      3.How do you ensure that those you serve under this contract are eligible for the services you provide? FORMTEXT      4.Please describe your methodology for preparing billings to the Michigan Department of Human Services. FORMTEXT      5.How do you keep track of units of service that you provide? FORMTEXT      6.Do you have other contracts and/or other funding sources (i.e. grants, insurance, client payment or co-pay) for your agencys operations? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how do you ensure that you do not bill the same unitof service to more than one funding source? FORMTEXT      7.Do your employees prepare time sheets or activity reports that identify the hours worked on each different program or contract? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please attach a copy of a blank form that is used for timeand activity reporting. FORMTEXT      8.Do you have funding sources that reimburse you for actual costs incurred in providing services? 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FORMTEXT      Prepared by: (Please Print)Telephone NumberTitle: FORMTEXT      ( FORMTEXT    )  FORMTEXT       FORMTEXT      Signature:Date:For DHS useReviewed by: (Please Print)Telephone NumberTitle: FORMTEXT      ( FORMTEXT    )  FORMTEXT       FORMTEXT      Signature:Date:Follow-Up Action Planned FORMTEXT      Follow-Up Action Taken (Please describe actions taken and result of the action.) FORMTEXT      Signature:Date:Authority: Federal OMB Circular A-133 Completion: Required Penalty: Cancellation of ContractDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. 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