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Appendix A

EXAMPLES OF RISK EVALUATION

RISK ASSESSMENT FORM

AGENCY INFORMATION SUMMARY

Subrecipient Name

____________________________________________________

Federal ID#

____________________________________________________

Street Address

____________________________________________________

City, State, Zip

____________________________________________________

Telephone Number

____________________________________________________

Contact Person

____________________________________________________

List Each State Department That the Agency contracts with, Type Program(s), Contract Amount:

State Agency

Program

Grant/Contract Amount

_________________ ________________________________________ __________________
_________________ ________________________________________ __________________
_________________ ________________________________________ __________________
_________________ ________________________________________ __________________
_________________ ________________________________________ __________________
_________________ ________________________________________ __________________
_________________ ________________________________________ __________________

RESULT OF RISK ASSESSMENT

Evaluation Score Key:

   

TOTAL OVERALL SCORE

______

Low Risk

= < 25

 

(From Page 2)

 

Moderate Risk

= 26 - 34

     

High Risk

= 35 - 48

     

RISK ASSESSMENT

High

____________
 

Medium

____________
 

Low

____________

Type of Review to Be Conducted:

Fiscal

_____________

Both

__________
 

Program

 

No Review

__________

Risk Assessment Performed by:

____________________________________________
   

Date

____________________________________________

Page 1 of 2



RISK ASSESSMENT FORM

Size of staff for period being monitored:

 

Small (1-6)

= 1

Moderate (7-12)

= 2

Large (13 or more)

= 3

TOTAL

 

Staff qualifications for funded programs:

 

Trained staff in key positions with one or more years experience

= 2

At least half of staff trained in key positions and some experience.

= 4

Staff in key positions have little or no training or experience.

= 6

TOTAL

 

Staff turnover:

 

No change in key positions

= 2

Either new or no staff in 1 or more key positions

= 4

Either new or no agency administrator or fiscal officer

= 6

TOTAL

 

Program:

 

Agency has met program objectives outlined in contract/funding agreement

= 2

First year of funding for program (no basis for evaluation)

= 4

Program compliance history of past 2yrs include weakness in fulfilling objectives.

= 6

TOTAL

 

Fiscal:

 

No significant audit findings for past 2 years

= 2

Minor audit findings with pending corrective actions

= 4

Significant audit findings w/in past 2yrs or audit findings not resolved.

= 6

TOTAL

 

Reporting:

 

Program and fiscal reports are almost always submitted timely and accurately.

= 2

Routine reports are frequently late and contain errors.

= 4

Routine report are not submitted or contain significant discrepancies.

= 6

TOTAL

 

Complexity of Funding:

 

Funding is relatively simple in terms of allowable expenditures

= 2

Funding is moderately complex in terms of allowable expenditures (i.e. IV-B)

= 4

Funding is very complex in terms of allowable expenditures (i.e.TANF, IV-E)

= 6

TOTAL

 

Amount of Funding to Provider:

 

Less than $25,000

= 2

$25,000 - $299,999

= 4

$300,000 or more

= 6

TOTAL

 

Self Assessment:

 

Self assessment shows few or no internal control weaknesses

= 1

Self assessment shows several internal control weaknesses

= 2

Self assessment shows major internal control weaknesses

= 3

TOTAL

 

TOTAL OVERALL SCORE:

 

Page 2 of 2

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