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This document is an example of a case log that the ACF On-Site Review Team Leader or designee completes to account for the review and disposition of each sample case drawn for the review. The case log may be modified as determined necessary by the team leader.
State name: ___________________________
| Sample Number |
AFCARS Number | Reviewer | Compliance | Disallowance | Underpayment | QA | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| SC | NSC | Reason | Error | Non-Error | Total FFP | FFP | Reason | ||||
SC: Substantial Compliance
NSC: Non-Substantial Compliance
Main: Amount of Maintenance Payment
Adm: Amount of Associated Administration Cost
FFP: Federal Financial Participation
QA: Quality Assurance Review of the Sample Case (Indicate the initials of individual completing the QA)
