Roster/ Sample Matrix

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Offsite _____ Phase I _____ Phase 2 _____ Prov. # ___________________
CENTERS FOR MEDICARE & MEDICAID SERVICES
RosteR/sample matRix
ReVieW
FoR sURVeYoR Use
ResiDeNt CHaRaCteRistiCs
total sample:
Phase 1
Phase 2
Individual Interview (i)
Family Interview (F)
Closed Record (Cl)
Comprehensive (C)
Focused Review (F)
pHYsiCal
QUalitY
elimiNatioN
NUtRitioN
FUNCtioN
oF liFe
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 35 36 37
Form CMS-802 (10/10)

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