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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 5, Chapter 16:  Manual Exhibit 5-16-B

Self-Assessment Questionnaire


__________________________________________________________________
(Management Control Area)
______________________
(Area Office)

A written explanation is required for all "NO" and "N/A" responses.

  1. Objectives.  A self-assessment questionnaire should be used to check for Federal Managers’ Financial Integrity Act (FMFIA) compliance and to seek data or other specific information.  All self-assessments should be able to identify the following:

    1. Major work activities that are critical to accomplishing the work objectives.

    2. Mechanisms that test or allow you to evaluate the control objectives.

    3. Product/deliverables that measure the accomplishment of the work objectives.

    4. Schedule for completion.

    5. Consequences of the work objectives not being met.

  2. Questionnaire.  The self-assessment questionnaire should be 1 to 2 pages in length and contain no more than 20 to 30 questions.  Questions should be derived from existing laws, regulations, and policies related to the subject area.  Examples follow:

    1. Compliance Question.  A compliance question should be worded such that a “Yes” answer signifies compliance, and a “No” answer signifies non-compliance.  It is appropriate to ask for documentation to support a “Yes” answer.  For example: “Does the Area have the following control (i.e., law, regulation, policy) in place?” YES_____ NO_____

      If yes, please provide a copy of _____________________________________________.

    2. Open-Ended Question.  An open-ended question is an opportunity for gathering information.  For example:  Open ended questions should begin with words such as “why” and “how” or phrases such as “Describe ______________ process,” or “Provide examples of ______________, etc.”

    3. Document Testing and Sampling.  Evidence collection for the Circular A-123 Appendix A, “Internal Controls Over Financial Reporting” assessment, if applicable.

  3. Status of Corrective Action Plans.  The self-assessment questionnaire must include a separate question for reporting on the status of the prior year corrective action plans (CAP).  The status report should:

    1. indicate the status of the identified corrective actions as on schedule, revised, or completed;

    2. describe major accomplishments made during this reporting period; and/or

    3. describe how the corrective action resolved the deficiency.

  4. Other Issues.  The self-assessment questionnaire should include an open-ended question for the Area to report on other issues that are not addressed in the questionnaire.  This is an opportunity for the Areas to list or describe any other issues related to this MCA not addressed in the self-assessment questionnaire that are believed to be important enough to bring to the attention of Headquarters.

  5. Certification.  All self-assessment questionnaires must be certified and signed by the Area Director with the following statement: “I hereby certify that all information provided in this questionnaire is accurate and complete to the best of my knowledge.”

Certification Statement.

I hereby certify that all information provided in this questionnaire is accurate and complete to the best of my knowledge.

__________________________________________________________________
(Please type name of person signing here)
Area Director
Note:  A stamped signature of the Area Director will not be accepted.
________________________________________
Date


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