Assistance - Template

Site Name:

Address:

City:

County:

State:

Zip:

Directions:

Section:

Tier:

Range:

Long:

Lat:

Assistance ID:

Staff Assisting:

Program Type:

Contact:

Action Date:

Report

Attached Files/Reports

File Name	File Type	File Date	Note

Comments

Date	Comment	Commenter
12/14/2010	We discussed the facility's record-keeping requirements over the phone since Tom was not present during my inspection. He handles all the records for the facility.	MICHELLE JOHNSON

Assistance Details:

Field Office Compliance - Assistance