Form Sr 2b-Wp - Social Work Component Program Audit Working Paper
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1STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
INITIALS
DATE
SOCIAL WORK COMPONENT PROGRAM AUDIT
Prepared By:
WORKING PAPER (SR 2B-WP)
Approved By:
PROVIDER NAME:
PROGRAM NAME:
PROGRAM NUMBER:
PROGRAM AUDIT DATE:
EMPLOYEE/CONTRACTOR:
AUDIT PERIOD:
DATE HIRED:
DATE TERMINATED:
A. EVIDENCE OF CCL COMPLIANCE (FOR PAYROLL SOCIAL WORKERS):
In file?
YES
NO
Dates: ________ FP submission ______ Association ________Exemption ________ Child Abuse Index
B. PAYROLL/CONTRACT HOURS (SR 2B - Column A)
YES
NO
Documentation Reviewed:
Contract
Agency Payroll Records
Timesheets
Client Files
Other - Specify:_____________________
C. “DIRECT HOURS” CONTRACT (SR 2B - Column C1) (Refer to MPP Section 11-402.222(d))
YES*
NO
If YES, complete SW Direct Contact Contract Worksheet
Documentation Reviewed:
Contract
Personnel Records
Itemized Billing Statement
Client Files
Other - Specify: ____________
D. PROFESSIONAL LEVEL (Refer to MPP Sections 11-402.222(a) and (b))
Professional Level Reviewed:
Reported:
LCSW (2.5)
MFT (2.5)
MSW (2.0)
MSC (2.0)
MA/eligible for MFT
Pre-1990 or
Or ACSW (Intern)
60 units
exam (1.75)
BSW + 2 years
60 units
experience (1.5)
Verified:
LCSW (2.5)
MFT (2.5)
MSW (2.0)
MSC (2.0)
MA/eligible for MFT
Pre-1990 or
or ACSW (Intern)
60 units
exam (1.75)
BSW + 2 years
experience (1.5)
None verified
License No.______________________
Other/Specify: __________________________________________________________________________________________________
Documentation Reviewed:
Consumer Affairs License
Transcripts
Diploma
Other-Specify: ____________________________
Internet Verification
Registration (Intern/Associate)
If weighting different from provider’s weighting:
No current license on file for LCSW/MFT
No documentation for education claimed
Employee does not qualify as a social worker
SR2B-WP (12/02)
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