This form is used to refer a participant to be contacted for a QC review or to sanction a participant for refusal to cooperate with a QC review.
NUMBER OF COPIES AND DISPOSITION:
One copy, to be completed in part by the QC Reviewer, and then sent to the FSD Caseworker and Supervisor I, upon completion of requested action, FSD will copy and send to the QC Reviewer. Retain one copy to be filed in the case record.
Food Stamp Manual section 1140.050.00, Quality Control Review Noncompliance
INSTRUCTIONS FOR COMPLETION:
To be completed by the QC Reviewer and IM Caseworker.
Enter the participant's name, address, telephone number, DCN, Social Security number, and IM Caseworker's load number.
FSD CASEWORKER/SUPERVISOREnter the participant's caseworker's name and supervisor's name.
ACTION ATTEMPTED BY QC REVIEWERQC Reviewer enters the type (types) of contact they have attempted, the dates of the attempt, and any comments they have. The QC Reviewer enters his/her name, date, telephone number, and address.
TO BE COMPLETED BY FSD
The FSD IM Caseworker completes this portion noting the action taken, if the address was verified, if they established refusal to cooperate, any notices sent, the dates the notices were sent, and any comments. The worker lists his/her name, supervisors name, telephone number, signature, and date. Once completed the FSD IM Caseworker retains one copy of the form for the case record and returns one to the QC Reviewer.
NOTE: The IM Caseworker must enter comments into FAMIS to document what action has been taken and the final result.