Medical Devices Contract Quarterly Summary Report 2023.xlsx

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Overview

Coversheet
StateReport
DivisionReport
Instructions

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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

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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

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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.

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Sheet 4: Instructions