The School Board of Broward County, Florida
Why Were You Selected ?
You are probably wondering why you have been asked to complete a
Random Moment Sample (RMS) form.
The School Board of Broward County participates in a program
called the Medicaid Certified School Match program.
The Administrative Outreach Claiming portion of this program
reimburses the school district for helping students and their families
access health and therapy services.
This program has been a significant revenue source for the
District and allows for enhancements to Student Support and
Exceptional Student Education services in Broward schools.
To learn more about this program please visit our website at:
http://www.broward.k12.fl.us/studentsupport/Operations/medicaid.htm
How Was Your Name Selected ?
Your name was randomly selected based on your Florida Department of Education Job
Title and it’s description.
The district uses a software product to randomly select staff and randomly assign
moments to be sampled. The software generates the printed Random Moment Sample
forms that you receive.
Your name can be randomly selected more than once a quarter and more than once a
year.
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If you have received a letter directing you to watch this
presentation, you will soon receive a survey form that you are
required to complete.
Data gathered from the Random Moment Sample form is used
for potential reimbursement from activities that our district staff
perform.
The school system is required to remit all participant forms at
the end of each quarter.
Be sure to indicate exactly what you were doing at your
moment in time as it relates to the academics, behavioral,
administrative or medical concerns.
These forms are permanently retained and read by state and
federal auditors. Please word your response in a professional
HOW TO STATE AN ACTIVITY
Let’s go over the instructions and review a few examples.
The instructions for this section read as follows:
Please use the spaces below to describe the activity in which you were
involved at the exact moment of your random sample time. It will be
necessary for you to be as specific as possible when writing your
response. Document exactly what issues, ideas, or services were being
conveyed at that time as it relates to the academics, behavioral,
administrative or medical concern. Review the example sentences on the
back of this form to help you illustrate how to accurately record a detailed
account of your sample moment.
When you document your activity, you do not need to use the entire
space. Describe your activities for just the one minute you were
assigned. Please do not document multiple tasks. Your statement
should reflect who you were with, what you were doing, and why
you were performing the activity. Remember the terms who, what,
and why !
TWO SECTIONS TO THE RMS FORM
You are being asked to complete the survey form by writing a
short response describing your activities during one specific
moment in time (example: June 3, 2014 @ 8:32 a.m.). You will
receive the actual form, along with detailed instructions,
approximately three days prior to your assigned date of
documentation. It is mandatory that you complete your form
and return it to the ESE & Support Services – Medicaid/504
Department immediately after completion.
There are two major sections of this form that you will
need to complete. These consist of . . .
Section 1
the Activity portion,
IMPORTANT REMINDERS
and Section 2
the Signature and Date portion.
EXAMPLES
The sentence . . .
“I was in an IEP Meeting.” is too vague. A more specific response is . . .
“I was in a meeting explaining an ESE student’s annual goals to the student’s parent”.
Notice that in the example the name of the committee, such as “IEP”, was replaced with specific
details. It is not enough to say you were writing or discussing goals. It is important that we know
who you were with and what was being discussed (or being done) and for what purpose, so that the
form may be coded properly. We need to know if the topic was focused on academic, behavioral,
administrative, or medical concerns.
Here is another example . . .
“I was talking to a teacher about a student’s progress in therapy. While we were talking,
another student’s mother called and we discussed his classroom behavior. I suggested he
receive a hearing evaluation. I then went to lunch.”
This statement reflects too many activities. Think about what you actually did during your moment in
time. If you were multi-tasking, what task would you continue doing if you could only work on one?
A better response is . . .
“I was talking to a teacher about a student’s progress in therapy.”
While it is important to refrain from giving too much information, it is also important to refrain from
giving too little information. For instance . . .
“I was driving in my car.” . . . is too vague.
Do tell us where you were going to and from.
“I was driving back to work from a training session on how to use behavior
modification techniques in the classroom with students diagnosed as hyperactive.”
SECTON 1 - ACTIVITY PORTION
WHO ? WHAT ? WHY ?
The response written in the Activity portion
of the form should answer the following 3
questions:
Who were you with?
What were you doing?
Why were you doing this?
(Who - student’s parents and teachers)
( What - discussing the student’s difficulty with
gross motor skills)
(Why - to determine if an evaluation for OT/PT
is needed)
Keep In Mind . . .
If at your selected moment you were not scheduled to work or you were at lunch, please
indicate that in the area below and proceed to complete the rest of the form. No further
description is required if at lunch or not scheduled to work.
If you make an error while completing the form, please cross out the error and initial,
and date the change you are making and continue to complete the form.
JOB TITLE
When indicating your Job Title, it is
important to write your Job Title exactly
as it appears at the top of the form.
This Job Title reflects the Florida
Department of Education Job Title that
corresponds with your Job Description
and may not be the same as the School
Board of Broward County Job Title that
you are familiar with.
For example, Behavioral Specialists and
Support Facilitators can expect to see
“Teacher, Varying Exceptionalities” as
their Job Title on their form.
* If the Job Title on the form is not
descriptive of your position, please
contact our office as soon as
possible at 754-321-3400.
SECTION 2: SIGN AND DATE WITH
CORRECT JOB TITLE
Now you are ready to complete the
Signature and Date portion of the form.
Once you have answered section 1 and
review the important reminders, please be
sure to complete the bottom of the form by
Signing your Name, Indicating your Job
Title, and Dating the Form.
FINISHING UP
Please be sure to provide us with your work telephone
number (including Area Code).
Please remember that completing and dating the form prior
to your assigned date will invalidate the form.
MAILING AND CONTACT INFORMATION
As soon as you have completed the Random Moment Sample form, please
return it to our office using the pre-addressed label provided with the form.
Our address is :
ESE & Support Services – Medicaid/504 Dept.
Arthur Ashe 2nd Floor,
Attn: Carmen Sotolongo
If you do not receive your Random Moment Sample form via pony within
two days of your assigned date, please contact our office at: 754-321-8462.
Thank you for your time and cooperation with this program.
Deneen Gorassini - Medicaid Coordinator
Lisa-Ann Clarke - Medicaid Accountant
Nanci English - Customer Service Analyst