Medical Devices Contract Quarterly Summary Report 2023.xlsx

Standardized Reporting Forms for Federally Funded Public Health Projects and Agreements

Medical Devices Contract Quarterly Summary Report 2023.xlsx

OMB: 0910-0909

Document [xlsx]
Download: xlsx | pdf

Overview

Coversheet
StateReport
DivisionReport
Instructions


Sheet 1: Coversheet









OMB Number: 0910-0909 Exp Date: XX/XX/XXXX See bottom of page for PRA statement





















































































Contract Number (auto-filled)
Select Agency





Agency Name (select from list)
Select

State or US Territory (auto-filled)
Select Agency





Contract Type
MDV





Date Completed (MM/DD/YYYY)







State Report Preparer's Name


State Report Preparer's Email






































Period of Performance Start Date













Period of Performance End Date













Reporting Period Start Date













Reporting Period End Date













Reporting Period Frequency
Select











Current Reporting Period
Select





































































































































Sheet 2: StateReport








Contract Reporting Elements Line Item
(for current option)
Total Contract Requirement Total Completed
(this reporting period)
Total Remaining

Contract Work Accomplished Contract Inspection Types




1. QSIT Level I 0 0 0 0

2. QSIT Level II 0 0 0 0

3. Other - Training (dollar amount) 0 $0.00 $0.00 $0.00

State Contract Actions 4. Enforcement Notices (e.g. warning letters)

0

5. Embargoes/Seizures

0

6. Hearings Conducted

0

7. Prosecutions/Injunctions

0

Other Contract Actions List Below




8. [Replace bracketed text]

0

9. [Replace bracketed text]

0

10. [Replace bracketed text]

0

11. Re-Inspections (Follow-ups to violative Inspections)

0








State Contractor Challenges, Issues, and Highlights

12. Select the current status based on your assessment of contract performance for this reporting period. Select

13. List any major challenges encountered this reporting period and corrective actions taken. Include how these actions directly address those challenges.

14. Write a brief narrative detailing any positive, significant events identified during this reporting period.

15. If applicable, report a dollar value for Item 5. Embargos/Seizures from the table above.

16. Additional State Reporting Comments












Sheet 3: DivisionReport





Contract Performance Feedback

17. Indicate the overall status of the State contractor's performance this reporting period. Select

18. (Optional) If the contractor experienced challenges or issues during this reporting period, please list them and detail any corrective actions taken or agreed to by the contractor.

19. (Optional) Write a brief narrative detailing any positive, significant events identified during the contractor's performance this reporting period.

20. Indicate Division Approval or Disapproval by selecting from the drop-down menu. If this report is disapproved, provide your explanation below. Select



21. (Optional) Additional Division Reporting Comments.

22. Enter the name of the Division Representative approving this report.

23. Enter the date this Division Review was completed.









Sheet 4: Instructions














































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