EVV Data Audit Checklist Form
Use this form to review EVV records for completeness, accuracy, and required verification checks.
Audit Identification
Audit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Auditor Name
*
Organization / Site or Program Name
*
Audit Period Reviewed
*
EVV Record Review Checklist
EVV Record or Visit ID
*
Service Date and Time Reviewed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
EVV Verification Items
*
Rows
Passed
Failed
Not Available
Not Applicable
Visit Start Time
1
2
3
4
Visit End Time
5
6
7
8
Location Verification
9
10
11
12
Service Documentation
13
14
15
16
Caregiver/Client Match
17
18
19
20
Discrepancies and Corrective Action
Discrepancy Type(s) Found
*
Missing check-in
Missing check-out
Location mismatch
Time variance
Incomplete notes
Duplicate entry
Other
Brief Findings / Notes
Corrective Action / Follow-up Required
Final Audit Outcome
Overall Audit Result
*
Passed
Passed with Findings
Failed
Overall Severity / Confidence
*
1
2
3
4
5
Auditor Final Comments
Submit
Should be Empty: