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<br />EXHIBIT A <br /> <br />Assessments for these facilities can be automated using ~e (CASA) import feature. The <br />following issues must be considered prior to an automated assessment: <br /> <br />* <br /> <br />Can only be used if complete immunization histories are entered into computer database. <br /> <br />* <br /> <br />Methodology used for an automated assessment must be approved by RECEIVING <br />AGENCY as meeting contract requirements. <br /> <br />* <br /> <br />Complete enumeration should be performed (i.e., CASA sampling feature is not used). <br /> <br />Assessment Criteria # 1 <br /> <br />CASA Assessment Site Requirements <br /> <br />CASA Client Information <br /> <br />Provider Review Date <br />Common Review Date: Same as Provider Review Date <br />Provider Type <br />Name of Assessed Site <br />Reviewer Initials <br />Address <br />City, Zip Code <br />County Code <br /> <br />FULL Last and First Name <br />Date of Birth (12-23 and 24-35 months of age from date of <br />assessment) <br />Moved or Gone Elsewhere <br />Number of Medical Visits (Medical Charts Only) <br />Shot Type <br />Shot Date <br />Gender <br />SS Number <br /> <br />.' <br /> <br />Assessment Criteria #2 <br /> <br />CASA Assessment Site Requirements <br /> <br />CASA Client Information <br /> <br />Provider Review Date <br />Common Review Date: Same as Date of Assessment <br />Provider Type <br />Name of Assessed Site <br />Reviewer Initials <br />Address <br />City, Zip Code <br />County Code <br /> <br />FULL Last and First Name <br />Date of Birth (12-23 and 24-35 months of age from date of <br />assessment) <br />Moved or Gone Elsewhere <br />Number of Medical Visits (Medical Charts Only) <br />Shot Type <br />Shot Date <br />Gender <br />SS Number <br /> <br />Rev. 5/98 <br />