Form Sr 2-Wp - Entrance Questionnaire
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Initials
Date
Prepared By
ENTRANCE QUESTIONNAIRE (SR 2-WP)
Approved By
PROVIDER NAME:
RESPONDENT
PROGRAM NUMBER:
PROGRAM AUDIT DATE:
1.
Date/Time:
Audit Period:
2.
Location:
3.
CDSS Auditors:
4.
Provider Staff:
Title:
Title:
Title:
Title:
5.
How many programs does the corporation operate? (FFAs, schools, other GHs, etc.)
6.
Describe primary services/activities of this program:
7.
Describe major sources of funding specific to this program (include source/type of offsets):
YES
NO
Are recent fiscal year financial statements available?
8.
a.
Organizational chart available?
YES
NO
b.
Who are the 1st line supervisors and where do they work? _________________________________________
_______________________________________________________________________________________
YES
NO
c.
Does the program have staff performing multiple functions?
(e.g., works half-time in administration, half-time as child care worker, etc.)
d.
Who are the multiple function people? _________________________________________________________
_______________________________________________________________________________________
9.
PAYROLL SYSTEM
a)
How do you monitor points? ____________________________________________________________________________________
b)
Who prepares payroll? ________________________________________________________________________________________
c)
How often are employees paid? _________________________________________________________________________________
d)
What is the standard workweek? (e,g., Sun - Sat) ___________________________________________________________________
e)
Hourly pay scale range? (CCS, SW, MH) __________________________________________________________________________
f)
Salary pay scale range? (CCS, SW, MH) __________________________________________________________________________
YES
NO
g)
Pay codes available? (funding source AFDC-FC and Non AFDC-FC and job titles) . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
h)
Any in-kind payments? (e.g., room and board). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
i)
Is there a pay differential for different shifts? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
j)
Do any staff volunteer hours? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SR 2 - WP (12/02)
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