Appendix A

EXAMPLES OF RISK EVALUATION

RISK ASSESSMENT FORM

AGENCY INFORMATION SUMMARY

Subrecipient Name	____________________________________________________
Federal ID#	____________________________________________________
Street Address	____________________________________________________
City, State, Zip	____________________________________________________
Telephone Number	____________________________________________________
Contact Person	____________________________________________________

List Each State Department That the Agency contracts with, Type Program(s), Contract Amount:

State Agency	Program	Grant/Contract Amount
_________________	________________________________________	__________________
_________________	________________________________________	__________________
_________________	________________________________________	__________________
_________________	________________________________________	__________________
_________________	________________________________________	__________________
_________________	________________________________________	__________________
_________________	________________________________________	__________________

RESULT OF RISK ASSESSMENT

Evaluation Score Key:		TOTAL OVERALL SCORE	______
Low Risk	= < 25	(From Page 2)
Moderate Risk	= 26 - 34
High Risk	= 35 - 48

RISK ASSESSMENT	High	____________
	Medium	____________
	Low	____________

Type of Review to Be Conducted:	Fiscal	_____________	Both	__________
	Program		No Review	__________

Risk Assessment Performed by:	____________________________________________

Date	____________________________________________

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RISK ASSESSMENT FORM

Size of staff for period being monitored:
Small (1-6)	= 1
Moderate (7-12)	= 2
Large (13 or more)	= 3
TOTAL
Staff qualifications for funded programs:
Trained staff in key positions with one or more years experience	= 2
At least half of staff trained in key positions and some experience.	= 4
Staff in key positions have little or no training or experience.	= 6
TOTAL
Staff turnover:
No change in key positions	= 2
Either new or no staff in 1 or more key positions	= 4
Either new or no agency administrator or fiscal officer	= 6
TOTAL
Program:
Agency has met program objectives outlined in contract/funding agreement	= 2
First year of funding for program (no basis for evaluation)	= 4
Program compliance history of past 2yrs include weakness in fulfilling objectives.	= 6
TOTAL
Fiscal:
No significant audit findings for past 2 years	= 2
Minor audit findings with pending corrective actions	= 4
Significant audit findings w/in past 2yrs or audit findings not resolved.	= 6
TOTAL
Reporting:
Program and fiscal reports are almost always submitted timely and accurately.	= 2
Routine reports are frequently late and contain errors.	= 4
Routine report are not submitted or contain significant discrepancies.	= 6
TOTAL
Complexity of Funding:
Funding is relatively simple in terms of allowable expenditures	= 2
Funding is moderately complex in terms of allowable expenditures (i.e. IV-B)	= 4
Funding is very complex in terms of allowable expenditures (i.e.TANF, IV-E)	= 6
TOTAL
Amount of Funding to Provider:
Less than $25,000	= 2
$25,000 - $299,999	= 4
$300,000 or more	= 6
TOTAL
Self Assessment:
Self assessment shows few or no internal control weaknesses	= 1
Self assessment shows several internal control weaknesses	= 2
Self assessment shows major internal control weaknesses	= 3
TOTAL
TOTAL OVERALL SCORE:

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