Please answer every question, attaching materials & providing comments/explanations.
Legal Name Of Organization:
Address:
City:
Fiscal Contact Person:
State:
Grant Year:
Zip Code:
Phone: E-Mail:
Indicate whether your organization is: a federally qualified health center or look-a-like
a primary care association
a health center controlled network
other, specify:
Please attach a copy of the most recently completed, audited financial statement and A-133 audit. If your agency did not reach a threshold to complete an A-133 audit, please provide your most recent external financial audit.
Date of most recent report issued:
Period covered by most recent report issued:
Company completing audit:
Contact Information:
Do you have a job cost system? YES NO
If no, how do you segregate activities by fund source and year?
Which of the following best describes your organization’s accounting system?
Manual Automated Combination
How frequently do you post to the general ledger? daily weekly monthly other
Does the accounting system track completely and accurately the receipt and
disbursement of funds by each grant or funding source?
YES NO
If no, please explain why:
Are common or indirect costs accumulated into cost pools for allocation to projects,
contracts, and grants?
YES NO
©National Association of Community Health Centers, Inc., and Community HealthCorps® (UPDATED
09/11/2015). Proprietary information of NACHC intended for use by NACHC & authorized recipients. Do not publish, copy or distribute this information in part or whole without prior written consent from NACHC.
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Are the following books of account maintained?
General Ledger
Cash Receipts Journal
Cash Disbursements Journal
Payroll Journal
Original Documentation (e.g., timesheets, invoices, etc)
Yes/No Number of years maintained
YES NO
YES
YES
YES
YES
NO
NO
NO
NO
Purchase Journal
General Journal
Other
YES NO
YES NO
YES NO
Describe:
Does the accounting system provide for the recording of actual grant/contract costs according to categories of your approved budget[s], and provide for current and complete disclosure?
YES
NO
If no, explain why:
Are time and activity distribution records maintained by funding source and project for each employee to
account for total hours [100%] devoted to your organization? YES NO
If no, explain why:
Is your organization in compliance with federal cost principles? YES NO
Is your organization in compliance with procedures for the determination and allowance of costs in connection
with federal grants and contracts? YES NO
For the two (2) most recent A-133 audit reports, check Qualified or Unqualified:
Opinion from Auditors : Qualified Unqualified
Internal Controls: Qualified Unqualified
Compliance: Qualified Unqualified
Were there any Management Letter Comments? If yes, please explain (and attach any letters / documentation):
In your latest audit, how did the auditors assess your risk level?
Was the AmeriCorps program considered a “major” program for review in the last two A-133 audits?
©National Association of Community Health Centers, Inc., and Community HealthCorps® (UPDATED
09/11/2015). Proprietary information of NACHC intended for use by NACHC & authorized recipients. Do not publish, copy or distribute this information in part or whole without prior written consent from NACHC.
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How do staff record and report their time?
Does the time staff report on timesheets correspond to financial reporting? YES NO
How is this resolved?
Are employee time sheets signed by the employee and a supervisor? YES NO
Are the duties of the bookkeeper/record keeper separate from cash functions (receipt or repayment or cash)? YES NO
Are checks signed by individual[s] whose duties exclude recording cash received, approving vouchers for payment and the preparation of payroll? YES NO
Are purchase approval methods documented and communicated? YES NO
Are accounting entries supported by appropriate documentation? YES NO
Are cash or in-kind matching funds supported by appropriate documentation? YES NO
Are employees who handle funds bonded against loss by reasons of fraud or dishonesty? YES
NO
Are there procedures for complying with the applicable cost principles and the conditions of the award?
YES NO
Comments/Explanations:
The total number of attachments:
Includes:
Audit[s] and/or corresponding management responses to any findings
Other:
Prepared by: Date:
Title and Printed Name:
E-Mail: Telephone:
©National Association of Community Health Centers, Inc., and Community HealthCorps® (UPDATED
09/11/2015). Proprietary information of NACHC intended for use by NACHC & authorized recipients. Do not publish, copy or distribute this information in part or whole without prior written consent from NACHC.
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Please Note: This part of the Financial Management Survey helps provide NACHC with additional understanding of your management and sustainability of the Community HealthCorps program. This will not be used in making any federal grant determinations.
(Example) Stipends $120,000 $0 Community HealthCorps Grant (Federal funds)
Personnel (only directly involved with the operation of the program)
Salaries / Fringe Benefits
Travel
Staff
Member
Supplies
Criminal Background Checks
Contractual and Consultant
Training
Staff
Member
Evaluation
Other Program Operating Cost
Members Cost
Stipend/Living Allowance
Member Support Costs
FICA
Health Insurance
Workman’s Comp
Other benefits (please define)
TOTAL COST OF PROGRAM
What is the total estimated amount to be spent on the Community HealthCorps Program?
What is the total estimated amount of matching funds used to support the Community HealthCorps program?
How much in matching funds is cash?
How much in matching funds are in-kind donations?
Are any of the matching funds from federal or state agencies? How much?
Please list other federal or state agency funds that support this program:
©National Association of Community Health Centers, Inc., and Community HealthCorps® (UPDATED
09/11/2015). Proprietary information of NACHC intended for use by NACHC & authorized recipients. Do not publish, copy or distribute this information in part or whole without prior written consent from NACHC.
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