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Form 2.  TABLE of PROGRAM and FACILITIES DEFICIENCIES

October 2005 Version

Instructions:  For each deficiency noted on Form 1 (Checklist), enter the checklist number in the first column, and provide the information requested on this form.  This form can also be used to track corrections afterwards (see last column).  After Form 1 and 2 are complete, fill out Form 3 (Post-Assessment Documentation).

Line # from first column, Form 1

Location

Description of Deficiency, Reason(s) for the Deficiency, and Plan for Correction

Type of Deficiency

Timetable For Correction

(e.g. 30, 60, 90 days)

Date of Correction

Minor

Significant

Form 2 (Table of Deficiencies), Page 11

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