Title Page

  • Conducted on:

  • Region and HC

  • Regional towns visited:

  • Conducted by:

Travel purpose

Travel Agenda:

  • Purpose:

  • Other purpose for travel

Audits conducted:

  • Volume of audits conducted:

  • Trade:

  • Comments:

Observations

  • Were any trends noted during the physical assessments?

  • What was the nature of the trend?

  • Comments:

  • Appendixes:

Process and Procedures HCMP

Identified issue HC

  • Were issues identified?

  • What is the nature of the issue?

  • Comments:

  • Supporting evidence:

Process and Procedures DOC/AHS

Identified Issues DOC/AHS

  • Were issues identified?

  • What is the nature of the issue?

  • Comments:

  • Supporting evidence:

Meetings

HMC

  • Meetings:

  • Meeting
  • Location
  • Attendees

  • Issues Discussed

  • Issue
  • Comments

  • Outcomes

  • Tick the box if you have an issue that requires further follow up

  • Provided details for follow up

  • Add photo if required

DOC/AHS regional staff

  • Meetings

  • Meeting
  • Location
  • Attendees

  • Issues discussed

  • Issue
  • Comments

  • Outcomes

  • Tick the box if you have an issue that requires further follow up

  • Provide details for follow up

  • Add photo if required

Lessons learnt and Actions required.

  • Lesson learnt

  • lesson
  • Summary

  • Action required

Sign-off

  • Please sign once Summary is completed

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