PURPOSE: Use this form to:
NUMBER OF COPIES AND DISPOSITION: Make two copies. Keep one copy at the local level and send one copy to the Income Maintenance Program and Policy Unit at firstname.lastname@example.org , email@example.com , or firstname.lastname@example.org as appropriate.
INSTRUCTIONS FOR COMPLETION: The form may be typed, handwritten in ink, or the electronic version may be used.
OFFICE (S) AND/OR UNIT (S) IMPLEMENTING THIS PLAN: Enter the name of the county, region, or unit implementing the plan.
DATE: Enter the date this form is completed.
1. DESCRIPTION OF DEFICIENCY, INCLUDING ASSOCIATED ELEMENT AND ERROR CAUSE: Enter a description of the deficiency, what may cause the deficiency, and the results of the deficiency.
2. MAGNITUDE AND GEOGRAPHIC EXTENT OF DEFICIENCY AND DATA SOURCE USED: Identify how the deficiency was found, source of information that determined this, and how often this occurs.
3. COMPLETE DESCRIPTION OF ACTIVITY TO RESOLVE DEFICIENCY: Identify what activities will be done to help resolve the deficiency.
4. TASKS/STEPS, TIME FRAMES AND PERSON (S) RESPONSIBLE FOR EACH TASK/STEP: Describe the tasks to be done, who will be responsible for each task, and the target date for completion.
5. DESCRIPTION OF PLAN TO MONITOR IMPLEMENTATION TASK/STEPS AND TIME FRAMES: Identify the aspects of the plan, how they will be monitored, and when the monitoring will take place.
6. DESCRIPTION OF PLAN TO EVALUATE EFFECTIVENESS OF ACTIVITY TO RESOLVE DEFICIENCY: Describe how you will evaluate the effectiveness of the actions taken.
7. EXPECTED OUTCOME: Enter the outcome you are expecting to achieve.
8. AS OF THE DATE OF THIS PLAN/UPDATE, THE STATUS OF PERFORMING TASKS/STEPS, MEETING TIME FRAMES AND EFFECTIVENESS OF INITIATIVE TO RESOLVE DEFICIENCY: Identify any changes to the plan that need to be made or changes in time frames.
NAME AND TITLE OF PERSON WHO HAS OVERALL RESPONSIBILITY FOR THIS PLAN:
NAME: Enter the name of the person who will oversee the plan.
TITLE: Enter the title of the person who will over see the plan.
TELEPHONE NUMBER: Enter the telephone number of the person who will oversee the plan.