Roster/sample Matrix - Department Of Health And Human Services
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
Offsite _____ Phase I _____ Phase 2 _____ Provider # __________________
CENTERS FOR MEDICARE & MEDICAID SERVICES
RosteR/sample matRix
total sample:_______________
Phase 1 ____________________
Phase 2 ____________________
Individual Interview (I) ______
Family Interview (F) ________
Closed Record (CL) _________
Comprehensive (C) __________
Focused Review (FO) ________
Resident Name
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23
24 25 26 27 28 29 30 31 32 33 34
Form CMS-802 (04/12)
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Parent category: Medical