ࡱ> @ czbjbjצצ [*Bhhhhhhh|>>>8P܁|P,>~AAAAoBhBDC$N]OOOOOO$QRET Puh?CoBoB?C?C PhhAAPFFF?C.hAhANF?CNFFhhFA y>mCFwGP0PFUCUF||hhhhUhF?C?CF?C?C?C?C?C P P||#F||#CONTRACT MONITORING QUESTIONNAIRE ACTUAL COST 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 briefly describe your record keeping system (i.e. case files, session notes) 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.How do you keep track of the number of units of service that you provide? FORMTEXT      5.For each service included in your contract with DHS, please indicate the number of units of service that are expected to be provided for the year per the contract and the actual number provided to date. FORMTEXT      6.Please describe your methodology for preparing billings to the Michigan Department of Human Services. FORMTEXT      7.Do you have other contracts and/or other funding sources for your agency s operation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how do you allocate costs between the various contracts and funding sources? FORMTEXT      8.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      9.Do you have any employees who do not prepare time sheets or activity reports that identify hours worked oneach program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please list those employees and their job titles below. FORMTEXT      10.Please list employees charged in full or in part to this contract, and their positions. FORMTEXT      11.What fringe benefits do your employees receive? How do you allocate the cost of fringe benefits to the various programs you operate? FORMTEXT      12.How do you allocate costs for supplies, occupancy costs, contractual services, travel, and miscellaneous costs to the various funding sources? FORMTEXT      13.Do you charge an indirect rate? 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",.2XZ\^rtvԹԮꪟ㐅~s~g~\jh4UhI gCJOJQJaJjgh4U hT\*hI ghT\*hI gCJaJhT\*hI gCJOJQJaJjh4Uh4hT\*hGCJaJhT\*hCJOJQJaJhbMCJOJQJaJhT\*hGCJOJQJaJ hT\*hjh4Ujhx,UmHnHu$   $Ifgd5skdu$$Ifl08*v&04 la.v:y $Ifgd3g $Ifgd3gskd$$Ifl08*v&04 la. $Ifgd3gskd#$$Ifl08*v&04 la.0v:y $Ifgd3g $Ifgd3gskd$$Ifl08*v&04 la.02:X $Ifgd3gskd$$IflH08*v&04 la.XZ\v:y $Ifgd3g $Ifgd3gskdl$$Ifl08*v&04 la.vjjjjtjzjjjjjjknkpkkkkkkkllllll·µªԞti^j!h4UhT\*hI gCJaJjR h4Uh4hT\*hI gCJOJQJaJhCCJOJQJaJhtMCJOJQJaJjthx,UUj hx,U hT\*hRjhT\*hRUhT\*hRCJOJQJaJ hT\*hI gjh4Ujhx,UmHnHu$ jj s $Ifgd3gskdq$$IflH08*v&04 la.RMCHECKBOX NoIf yes, how is this rate computed? How do you ensurethat costs that are charged directly are not also included in the costs used to determine your indirect rate? FORMTEXT      14.What process do you use to ensure that costs billed are included in the contract budget for the program being charged? FORMTEXT      15.Do you have funding sources that pay a unit rate in addition to funding sources that reimburse for actualexpenses? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how do you ensure that the costs attributable to the unit rate contractare not billed to an actual cost reimbursement contract? FORMTEXT      16.How do you ensure compliance with applicable federal management circulars regarding cost principles for your organization (A-122 or A-87)? FORMTEXT      17.Do you have sub-contractors who provide services under this contract? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, pleasedescribe any monitoring procedures you have in place to ensure that the sub-contractor complies with the terms of the sub-contract. 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      SignatureDateAuthority: 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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DB@d2 Name: DB@d 2 Title: DB@d X DB@J"X DB@L DB@N]XF D!R!T.P6GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOXUserInfoName MYINFO.ini D%X P(VUserInfoTitle MYINFO.ini D%X P(ZUserInfoAreaCode MYINFO.ini D%X P("UserInfoPhone MYINFO.ini D%X P(\UserInfoYourExt MYINFO.ini D%X P(&UserInfoFaxAC MYINFO.ini D%X P((UserInfoFax MYINFO.ini D%X P(*UserInfoOffice MYINFO.ini D%X P(^UserInfoAddress MYINFO.ini D%X P(`UserInfoCity MYINFO.ini D%X P(bUserInfoState MYINFO.ini D%X P(dUserInfoZip MYINFO.ini D%X P(fUserInfoCO MYINFO.ini D%X P(hUserInfoDI MYINFO.ini D%X P(jUserInfoSEC MYINFO.ini D%X P(lUserInfoUN MYINFO.ini D%X P(nUserInfoWKR MYINFO.ini D%X P(pUserInfo Boss Name MYINFO.ini D%X P(@UserInfo Boss Title MYINFO.ini D%X P(B,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT P D!r%T'  OK BUTTONWRITE NEW USER INFO IN INI FILEUserInfoName P!V MYINFO.ini DB@tUserInfoTitle P!Z MYINFO.ini DB@tUserInfoAreaCode P!" MYINFO.ini DB@tUserInfoPhone P!\ MYINFO.ini DB@tUserInfoYourExt P!& MYINFO.ini DB@tUserInfoFaxAC P!( MYINFO.ini DB@tUserInfoFax P!* MYINFO.ini DB@tUserInfoOffice P!^ MYINFO.ini DB@tUserInfoAddress P!` MYINFO.ini DB@tUserInfoCity P!b MYINFO.ini DB@tUserInfoState P!d MYINFO.ini DB@tUserInfoZip P!f MYINFO.ini DB@tUserInfoCO P!h MYINFO.ini DB@tUserInfoDI P!j MYINFO.ini DB@tUserInfoSEC P!l MYINFO.ini DB@tUserInfoUN P!n MYINFO.ini DB@tUserInfoWKR P!p MYINFO.ini DB@tUserInfo Boss Name P!@ MYINFO.ini DB@tUserInfo Boss Title P!B MYINFO.ini DB@tGet user info from INI filekeUserInfoName MYINFO.ini D%X' UserInfoTitle MYINFO.ini D%X' orker8UserInfoAreaCode MYINFO.ini D%X' "tricUserInfoPhone MYINFO.ini D%X' $vUnit/UserInfoYourExt MYINFO.ini D%X' &NumbUserInfoFaxAC MYINFO.ini D%X' ( ClieUserInfoFax MYINFO.ini D%X' *UserInfoOffice MYINFO.ini D%X' , SeUserInfoAddress MYINFO.ini D%X' .onڶUserInfoCity MYINFO.ini D%X' 0UserInfoState MYINFO.ini D%X' 2tectDoUserInfoZip MYINFO.ini D%X' 4UserInfoCO MYINFO.ini D%X' 6rUserInfoDI MYINFO.ini D%X' 8esUserInfoSEC MYINFO.ini D%X' :UserInfoUN MYINFO.ini D%X' <HeUserInfoWKR MYINFO.ini D%X' >UserInfo Boss Name MYINFO.ini D%X' @,UserInfo Boss Title MYINFO.ini D%X' B  Update Form with user info Bord WorkerName D%vG workerName  DB@xjddress WorkerTitle D%vG WorkerTitle  DB@xjchWorkerAreaCode D%vGWorkerAreaCode " DB@xj WorkerPhone D%vG WorkerPhone $ DB@xjonWorkerExtension D%vGWorkerExtension & DB@xjmuFaxAC D%vGFaxAC ( DB@xjDat WorkerFax D%vG WorkerFax * DB@xj Countynumber D%vG Countynumber 6 DB@xj District D%vGDIstrict 8 DB@xjGrSection D%vGSECtion : DB@xjteUnit D%vGUNit < DB@xjkeWorker D%vGWorker > DB@xjame2sL CountyName D%vG CountyName , DB@xjStylea CoAddress D%vG CoAddress . DB@xjLefCoCity D%vGCoCity 0 DB@xjCasCoState D%vGCoState 2 DB@xjFCCoZip D%vGCoZip 4 DB@xjUseSupervisorName D%vGSupervisorName @ DB@xj ColSupervisorTitle D%vGSupervisorTitle B DB@xj. Update other Form Fields on Form & Exit Macroon|- Selected$=GetFormResult$ ("CurrentDate")UserD! TheSerialDate = Today() + 14 $ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$You) EditGoTo "CreateDate" : UnlinkFieldsri EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2Start/ ToolsProtectSection .Section = 2, .Protect = 0fo@d FileClose 2 SelectName = - 1nekpoh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! As Object: Se$t = CurValues. vGET USER INFO FROMI FILE AND@ PUT I NTOzx.t[GetPrivfileS@@ng$](" "'P:qMY.ini"r hl ? pa"4??>? Mpn_1r &.nAC `axU/-Y??>OMA\C$$a&gp Op | DIpp/-UN0 | {p y QaserInfo", "Boss Name`MYINFO.ini") dlgU.Title = WordBasic.[GetPrivateProfileString$]("t| 'DISPLAY DIALOG BOX AND RESPOTO USER INPUT iRet Dialog.p (If 3-1 Then 'OK BUTTON ?WRI@TE NEW3FO6I FILE xSx wYour ?, - -AreaCod|PhonEExtE@FaxACL+@OfficZ|Address0$ L+gCity ? : |StP  z Zo%  CoCity  ! CoStat$c b CoZip  "Supervi8sor<`, Boss! /Titl% b ' Upd. other  FieldsH on& t Macro Rem" SelA}ed$=G$ ("Curre8ntD9'`Serial = Today() + 14$5()lDure",a"GEditGoTo 0"Cre : Unlink'Grante@efirst3"ToolsProtDocum! .No@et`1, .Type@2/ .8= 2 `0 Else#FileClose D c.@- 1$nd #Sub }tSL??H    ! a !YY TemplateProject ThisDocumentMyInfoF /c:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLLVBA 1 Y` F5C:\Program Files\Microsoft Office\Office10\MSWORD.OLBWord )Qp0FC:\WINNT\System32\StdOle2.tlbstdoleDocument @ 9a.E .`M C:\WINDOWS\System32\FM20.DLLMSForms aatA2YB]1D 0C:\DOCUME~1\BushD2\LOCALS~1\Temp\VBE\MSForms.exd AaiL-[DR 2C:\Program Files\Microsoft Office\Office\MSO97.DLLOffice 1Yk FDW C mZ F`u pEܼy\ FMain Module1 UpdateField F Fy0 FyZrU~}    Enter Personal InformationNormal.MyInfo.MainbrU 0a94a0`rU @n__SRP_2+__SRP_3 .B__SRP_40T__SRP_5 2orU~| krU $`nrU~|  9l4-ptx$ 4x t @)xtr 4$ xtk__SRP_64__SRP_78gUpdateField:dThisDocumentPrU $`nj5txMEP6 LLL<<< `pk8x%8h PTUB1@Px 6@t :@p #>PHAB?$*\Rffff*2g45d2dc5d*\R1*#17b*\R1*#c1*\R1*#c6*\R1*#103"-( !B@o`XXAttribute VB_Name = "UpdateField" Sub D () ActiveDocu ment.Zs.P End p <jx55#<DW C mZ F`u pEܼy\x`u pEܼy\DW C mZME(SLSS6"N0{00020906-0000-0000-C000-000000000046}(%H` % %`h8@0AB?$*\Rffff*3V4566f5b24xAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2as  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#c:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{000209_VBA_PROJECTcPROJECTPROJECTwmbCompObjj05-0000-0000-C000-000000000046}#8.2#0#C:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINNT\System32\StdOle2.tlb#OLE Automation*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\System32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{324174C4-59D3-42D0-B45D-A131808E4494}#2.0#0#C:\DOCUME~1\BushD2\LOCALS~1\Temp\VBE\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M *\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#C:\Program Files\Microsoft Office\Office\MSO97.DLL#Microsoft Office 8.0 Object Library  AB?5ThisDocument3V4566f5b2ThisDocument5 MyInfo3W4566f5b2 MyInfou'UpdateField2g45d2dc5dUpdateFieldt8X8ҎlsBؤ [*I/f<`H5ctaAn(<>CD. Wordk VBAWin16~Win32MacVBA6# TemplateProjectEstdole`MSFormsCOfficeu ThisDocument< _Evaluate MyInfo@(Main,iRet,pUserName\ UserTitleV9AreaCode UserPhoneYourExthLFaxACjYourFaxrN UserOffice0 UserAddressFUserCity UserStateUserZipDUserCOUserDIUserSEC4UserUN0UserWKR,BossNamef BossTitleH WordBasic BeginDialogFTextBoxQOKButton| CancelButton EndDialogmP dlgUserInfo2" CurValuesȤ UserDialogYourName;RGetPrivateProfileString$x YourTitleA# YourPhone YourOffice YourAddressYourCity YourStateYourZipYourCOYourDIYourSECvYourUNVYourWKRnDialogfSetPrivateProfileString=ExistingBookmark SetFormResultDocumentj ConvertToPDFModule1b (UpdateFieldKActiveDocument\Fields7Updatel 6ID="{700A1D32-751F-46DD-A97D-FEAFD66F5599}" Document=ThisDocument/&H00000000 Module=MyInfo Module=UpdateField Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="2D2F2154FFC703C703C703C703" DPB="9C9E90C5903591359135" GC="0B09077A777B777B88" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C MyInfo=0, 0, 0, 0, C ThisDocumentThisDocumentMyInfoMyInfoUpdateFieldUpdateField@ bjbjצצ U"U"#w#w#w#w#w7w[wPP܁7wm,RNNNNN"p|ԍ֍֍֍֍֍֍$R-#wNN#w#wNN'#wN#wNԍԍ#w#w9|SN y[wȍ =0m7w7w#w#w#w#w#w7w7w$[w7w7w[w FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTE     !"#$%&'()*+,-./0123456&(*>@BLNPRfhvxz(*8:<PRTZ\^`tjiGhqgUjFhqgUjEhqgUj=EhqgUjDhqgUjDhqgUjHChqgUjhqgUmHnHujBhqgUhqgjhqgUjAhqgU1:^ Hj(Px@bZYXWVUTSRQPONMLKJIHGFEDCtv "68FHJ^`bfhjl觢{pj+MhqgUjzLhqgUjhqg5UmHnHujKhqg5U hqg5jhqg5Uj?KhqgUj|JhqgUjIhqgUjAIhqgUjHhqgUhqgjhqgUjHhqgU,&(*>@NPRfhvxzUjRhqgUj\RhqgUjQhqgUjPhqgUjOhqgUj OhqgUjNhqgUjMhqgUhqgjhqgUjhqgUmHnHu5XT        FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT     FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       .0>@BVX`bdxz "$&:<>DFHJ^jXhqgUjhqgUmHnHujWhqgUjYWhqgUjVhqgUjOVhqgUjUhqgUjThqgUjgThqgUhqgjhqgUjShqgU1$Hp(Pxjihgfedcba`_^]\[^`npr$&(*>@NPRfhvxzjH^hqgUj]hqgUjG]hqgUj\hqgUj[hqgUjhqgUmHnHuj7[hqgUjZhqgUjYhqgUhqgjhqgUjRYhqgU3 j[`hqgUj_hqgUhqgjhqgUmHnHujhqgUj^hqgU/ =!"#$%Address1 UppercasedEnter the Addressee's mail address (street address, PO Box, etc., where the mail will be delivered). ClientCityDBureau#Enter your Bureau/Office/Unit name.DCareOf UppercaseUEnter the Addressee's Supplemental Address (Example: Suite or Apartment Number, C/O)Address1D CaseNumber Uppercase/Enter the Case Number (Example: V1234567A,B,C)D ClientCity UppercaseEnter the Addressee's City. ClientStateD ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation. ClientZipD ClientZip UppercaseKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)D CoAddress UppercaseaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).D CoAreaCodeEnter the County's Area CodeDCoCity UppercaseEnter the County's City.D CoExtensiond8(OJQJ_HmH sH tH XOX CaseNumber1?d8(OJQJ_HmH sH tH XOX ClientCity1@d8(OJQJ_HmH sH tH ZOZ ClientState1Ad8(OJQJ_HmH sH tH ZO"Z ClientZip1BdtCJOJQJ_HmH sH tH VO2V CoAddress1Cd8(OJQJ_HmH sH tH XOBX CoAreaCode1 Dd`CJOJQJ_HmH sH tH PORP CoCity1Ed8(OJQJ_HmH sH tH ZObZ CoExtension1Fd8(OJQJ_HmH sH tH ^Or^ CoPhoneNumber1Gd8(OJQJ_HmH sH tH ROR CoState1Hd8(OJQJ_HmH sH tH ^O^ CoSuppaddress1Id8(OJQJ_HmH sH tH XOX CountyName1Jd8(OJQJ_HmH sH tH \O\ CountyNumber1 Kd`CJOJQJ_HmH sH tH ROR CoZip1LdtCJOJQJ_HmH sH tH NON Date11 Md`CJOJQJ_HmH sH tH TOT District2 Nd`CJOJQJ_HmH sH tH LOL FaxAC Od`CJOJQJ_HmH sH tH VOV FirstName1Pd8(OJQJ_HmH sH tH XOX FirstName21Qd8(OJQJ_HmH sH tH `O"` GranteeAddress1 Rd`CJOJQJ_HmH sH tH \O2\ GranteeCareof Sd`CJOJQJ_HmH sH tH XOBX GranteeCity Td`CJOJQJ_HmH sH tH `OR` GranteeClientID Ud`CJOJQJ_HmH sH tH dObd GranteeFirstName2 Vd`CJOJQJ_HmH sH tH bOrb GranteeLastName1Wd8(OJQJ_HmH sH tH ZOZ GranteeState Xd`CJOJQJ_HmH sH tH VOV GranteeZip Yd`CJOJQJ_HmH sH tH TOT LastName1Zd8(OJQJ_HmH sH tH VOV LastName21[d8(OJQJ_HmH sH tH ROR OtherID1\d8(OJQJ_HmH sH tH ROR Section2 ]d`CJOJQJ_HmH sH tH ^O^ SuperAreaCode1 ^d`CJOJQJ_HmH sH tH `O` SuperExtension1_d8(OJQJ_HmH sH tH dOd SuperPhoneNumber1`d8(OJQJ_HmH sH tH `O` SupervisorName1ad8(OJQJ_HmH sH tH LO"L Unit2 bd`CJOJQJ_HmH sH tH PO2P Worker2 cd`CJOJQJ_HmH sH tH `OB` WorkerAreaCode1 dd`CJOJQJ_HmH sH tH bORb WorkerExtension1ed8(OJQJ_HmH sH tH TObT WorkerFax fd`CJOJQJ_HmH sH tH XOrX WorkerName1gd8(OJQJ_HmH sH tH \O\ WorkerName2hd8(5OJQJ_HmH sH tH ZOZ WorkerPhone1id8(OJQJ_HmH sH tH ^O^ WorkerTitle1jd8(5OJQJ_HmH sH tH  ?0/Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumber CoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictFaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherID Section! 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