Module D: Member Documentation Compliance


Attachments Page

Attachment 28


Member Documentation in Files (Total Sheet)

Complete all information utilizing the AmeriCorps Member File Checklist for each member file. Review ten percent (10%) or ten (10) Member files; whichever is greater. On each Member sheet place an "X" in the appropriate column. Place totals for all files on this page.

Number of Member files sampled:

Are the following items in Member files?

Are the following items in Member files? Y N NA Comments
Member application
Member enrollment form signed and dated by Member
Proof of age (Driver's License, Birth Certificate, etc.)
Parental consent form (Members under 18)
Member contract sign and dated by Member
Criminal background check results
Were background checks reviewed if negative results were received? Is there a decision tree?
Timesheets signed and dated by Member and Supervisor
Documentation of citizenship/naturalization/resident alien status
High School Diploma or equivalency
Documentation of health care enrollment
Documentation of child care enrollment
Tax documents
Publicity release form
Member discipline documentation
Mid-term performance evaluation
End of term performance evaluation
Member End of Term/Exit Form
Documentation of Compelling Personal Circumstances (if applicable)
Family and medical leave coverage for Members where appropriate
Promptly notify changes to healthcare providers as required by the
Healthcare policy documentation for full time Members with no other
Document informing Member that if they receive Medicaid, they are
Information regarding loan forbearance
Change of Status/Term Form

Early Issue Detection

Are there any Member File issues not mentioned above?

What is the corrective action plan for those?


Member Documentation in Files (Member Sheet) (14 copies)

Complete all information utilizing the AmeriCorps Member File Checklist for each member file. Review ten percent (10%) or ten (10) Member files; whichever is greater. On each Member sheet place an "X" in the appropriate column.

Member's Name:

Are the following items in Member files?

Are the following items in Member files? Y N NA Comments
Member application
Member enrollment form signed and dated by Member
Proof of age (Driver's License, Birth Certificate, etc.)
Parental consent form (Members under 18)
Member contract sign and dated by Member
Criminal background check results
Were background checks reviewed if negative results were received? Is there a decision tree?
Timesheets signed and dated by Member and Supervisor
Documentation of citizenship/naturalization/resident alien status
High School Diploma or equivalency
Documentation of health care enrollment
Documentation of child care enrollment
Tax documents
Publicity release form
Member discipline documentation
Mid-term performance evaluation
End of term performance evaluation
Member End of Term/Exit Form
Documentation of Compelling Personal Circumstances (if applicable)
Family and medical leave coverage for Members where appropriate
Promptly notify changes to healthcare providers as required by the
Healthcare policy documentation for full time Members with no other
Document informing Member that if they receive Medicaid, they are
Information regarding loan forbearance
Change of Status/Term Form

Early Issue Detection

Are there any Member File issues not mentioned above?

What is the corrective action plan for those?