Form 5A Scope of Project Services Review

A compliance review form to confirm Form 5A accurately lists all in-scope services and modes of delivery for HRSA requirements.

Review Overview

• Review title
• Review date
• Review period start
• Review period end
• Reviewer name
• Reviewer role

Project and Site Information

• Project name
• Site name
• Site type
• Service area counties
  List counties or equivalent service area descriptors only if needed for the review.

In-Scope Services Review

• Services reviewed
• Are all in-scope services listed on Form 5A?
• If no, describe the missing in-scope services
  List only the services that are missing from the current Form 5A.
• Are service descriptions accurate and sufficiently specific?

Modes of Delivery Review

• Modes of delivery verified
• Are all applicable modes of delivery documented?
• If no, describe the missing or incorrect modes of delivery
  Include the service name and the specific mode of delivery that needs correction.
• If telehealth is used, is it documented appropriately?

Exceptions and Changes

• Are any out-of-scope items listed on Form 5A?
• If yes, describe the out-of-scope items
• Have there been changes since the last review?
• If yes, summarize the changes

Attestation and Submission

• I attest that this review accurately reflects the current Form 5A scope of project services.
• Is follow-up or correction needed?
• If yes, describe the follow-up needed