NAME:___________________________________________ AGENCY: ______________________________ OFFICE: _________________ 1 2 3 4 5 6 7 8 9 Audit / monitoring/ Dates Total Duration of Contact details of the Agency / Role in audit / Total Number Audit Criteria (e.g. QSS Type of audit Declaration of competence inspection Number (DD/MM/YY) audit / monitoring/ Institution (auditee) monitoring/ in Team Manual, Monitoring (The Team Leader declares that the audit inspection in days inspection (incl. yourself) Manual, MCs, OBMI) STATE: /monitoring/inspection was conducted PROVIDE: adequately and professionally and that the STATE: STATE: STATE: STATE: FIQA First presented information is accurate) – Agency / Institutions name Level Internal Start and finish Number of days Complete address LA - Lead Full Quality Audit PROVIDE: dates of the audit Telephone/fax Auditor Reference used SIQA Second – number: LE Lead Evaluator Level IQA Name of Team Leader – E-mail address LI Lead Inspector MON Position – – AU Auditor Monitoring Agency – EV Evaluator INS Inspection Contact telephone / fax number – – IN - Inspector COMP Email address – OB Observer Compliance – UN - Understudy
NAME:___________________________________________ AGENCY: ______________________________ OFFICE: _________________ 1 2 3 4 5 6 7 8 9 Audit / monitoring/ inspection Number Dates (DD/MM/YY) STATE: Start and finish dates of the audit Total Duration of audit / monitoring/ inspection in days STATE: Number of days Contact details of the Agency / Institution (auditee) PROVIDE: Agency / Institutions name Complete address Telephone/fax number: E-mail address Role in audit / monitoring/ inspection STATE: LA - Lead Auditor LE – Lead Evaluator LI – Lead Inspector AU – Auditor EV – Evaluator IN - Inspector OB – Observer UN - Understudy Total Number in Team (incl. yourself) Audit Criteria (e.g. QSS Manual, Monitoring Manual, MCs, OBMI) STATE: Full Reference used Type of audit STATE: FIQA – First Level Internal Quality Audit SIQA – Second Level IQA MON – Monitoring INS – Inspection COMP – Compliance Declaration of competence (The Team Leader declares that the audit /monitoring/inspection was conducted adequately and professionally and that the presented information is accurate) PROVIDE: Name of Team Leader Position Agency Contact telephone / fax number Email address