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Sc 1613 Form
Weeks of program operations. At least two of the three visits must
be unannounced. At least one unannounced review must include observation of a meal service.
Proposed Monitoring Dates (Month/Year)
(Identify which visits will be unannounced)
Name of Center
DSS Form 1613-4 (JUN 10)
Date of Last
Monitoring Visit
Scheduled for Current
Program Year
Visit 1
Visit 2
Visit...
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