Run NEMT OIG LEIE and SAM Exclusion Screening Log — Free

Inspection Details

Inspection month and year recorded critical (required)

Record the month being screened and the date the log was completed.

Note (optional)

Screening population identified critical (required)

Select all groups included in this monthly screening cycle.

Screening performed by authorized staff critical (required)

Enter the name or role of the person who performed the screening.

Reference policy or SOP used

Identify the internal procedure governing exclusion screening and follow-up.

Monthly screening cycle completed on time critical (required)

Confirm the monthly screening was completed for the current cycle without lapse.

Yes No N/A

OIG LEIE Screening

All covered individuals screened against OIG LEIE critical (required)

Verify each covered driver and staff member was screened against the OIG List of Excluded Individuals and Entities.

Yes No N/A

Screening date captured for each individual critical (required)

Confirm the date of each LEIE search is documented for audit traceability.

Yes No N/A

Search method documented critical (required)

Record how the LEIE search was performed.

No LEIE matches identified critical (required)

Confirm no exact or potential matches were found during the screening cycle.

Yes No N/A

Potential match resolved and documented critical (required)

If a potential match was identified, confirm the resolution steps and outcome are documented.

Yes No N/A

SAM.gov Screening

All covered individuals screened against SAM.gov exclusion records critical (required)

Verify each covered driver and staff member was screened against SAM.gov exclusion information as part of the monthly cycle.

Yes No N/A

Screening date captured for each SAM.gov search critical (required)

Confirm the date of each SAM.gov search is documented for traceability.

Yes No N/A

Search method documented for SAM.gov critical (required)

Record how the SAM.gov search was performed.

No SAM.gov matches identified critical (required)

Confirm no exact or potential matches were found during the screening cycle.

Yes No N/A

Potential SAM.gov match resolved and documented critical (required)

If a potential match was identified, confirm the resolution steps and outcome are documented.

Yes No N/A

Hire-Date and Ongoing Monitoring Controls

Pre-hire screening completed before start date critical (required)

Confirm exclusion screening was completed before the individual began covered work.

Yes No N/A

Monthly re-screening interval maintained critical (required)

Confirm no covered individual exceeded the monthly screening interval without documented review.

Yes No N/A

New hires added to screening roster within required timeframe critical (required)

Confirm newly hired covered staff were added to the screening roster promptly after hire.

Yes No N/A

Terminated or inactive staff removed from active roster

Confirm the roster reflects current active staff only and excludes terminated or inactive personnel.

Yes No N/A

Deficiencies, Corrective Actions, and Sign-Off

Deficiencies documented with affected individuals critical (required)

List any deficiencies, missed screenings, or documentation gaps and identify affected individuals.

Corrective action and follow-up due date recorded critical (required)

Document the corrective action taken, owner, and due date for completion.

Immediate removal from covered duties documented when required critical (required)

Confirm any individual with a confirmed exclusion or unresolved potential match was removed from covered duties pending resolution.

Yes No N/A

Inspector signature completed critical (required)

Inspector signs to attest the monthly screening log is complete and accurate.

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Run: NEMT OIG LEIE and SAM Exclusion Screening Log

Inspection Details

OIG LEIE Screening

SAM.gov Screening

Hire-Date and Ongoing Monitoring Controls

Deficiencies, Corrective Actions, and Sign-Off

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