Claim Investigation - DOC by wzh15891

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									    CENTER BLOCK CLAIM INVESTIGATION FORM
      State Agency Prototype Form: Attach this form to the Monitor Review Form of the same date and keep on file

 During an unannounced center visit, records were reviewed prior to claim submission and a
      block claim was identified
        BLOCK CLAIM MONTH                                                                    Year

 Investigation conducted after claim submitted to sponsoring organization
          BLOCK CLAIM MONTH                                                                  Year

Center/Site Name                                           Date of Center Visit

SO Monitor Name                                            Date Any Follow Up Action Completed

Check the meal types and list the dates identified as a block claim
    Breakfast    Dates:
    AM Snack Dates:
    Lunch        Dates:
    PM Snack     Dates:
    Supper       Dates:
    PM Snack     Dates:
YES NO
               Have any other meal types been previously block claimed and validated with a legitimate reason? If
               yes, list meal types:
               Were meal counts available for review? If yes, for what month:
               Were daily attendance records available for review? If yes, for what month?
               Were enrollment forms available for review?
What reason did the center director give for claiming the same number of children for the same meal or snack for 15
consecutive days?

YES     NO
                Was the SO monitor able to determine a legitimate/valid reason for the block claim?
                If Yes, monitor MUST provide specific comments to support the reason checked.
                Center cares for sick children. How is this communicated to parents?
                Monitor’s comments:


                Center has a very small enrollment. Monitor’s Comments:
                No. of families:_____ No. of children:_____

                Center has drop-in care and is always filled to capacity. Monitors Comments:
                No. of drop-in children present:_____

                Review of meal count, attendance and enrollment records appears to substantiate the block claim:
                Monitor’s Comments:


                Other:

If the block claim could not be validated, what follow up action was taken or needed? Attach applicable documentation.
                 Meal disallowance(s). Follow procedures set by sponsoring organization.
                 Household/Parent Contact
                 Scheduled additional unannounced center visits in near future
                 Other corrective action, explain:

                                                                                                                   8/2006

								
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