Nursing Facility
Internal Control and Cost Reporting Questionnaire

You are required by IDAPA 16.03.10.281.01.g to complete the enclosed questionnaire as part of your annual reporting requirements for the Medicaid program. The form is available for download at . Navigate to the download folder and click on the "Nursing Facilities" folder. A printed copy of the form is availableupon request for your use in completing it manually.All questions must be completed, and the entire form must be submitted along with the signed certification page.

Instructions for using the electronic form

  1. The electronic form is set up as a Word document and is password protected as no text, formatting, or other form changes are allowed. For this reason, information can only be keyed into the shaded answer areas or into the comment section on page 14 of the form.
  1. After the form has been completed, the file should be saved to your own computer and then copied back to a CD for submission to Myers and Stauffer. Only the password-protected version of the file will be accepted, so do not create and submit an “open version” of the file.
  1. For certification purposes, a printed and signed copy of the certification page must be submitted. Print, sign and date the Certification page (page15), and return along with the electronic file. We can accept either a hard copy or a PDF scan of the signed certification page.
  1. User Tips:
  • Use the TAB and Shift-TAB keys to move forward and backward between the answer fields in the form. Navigating around the form can also be done with your mouse, scroll bars, page up/down, etc.
  • Clicking on the (which appears to the right of the words “Choose below” in each answer field when selected) will bring a drop down “pick list,” where you can click on your response. Press the TAB key or use the mouse to continue.
  • Files cannot be re-saved directly to a CD. Instead, they must be saved to the hard drive and then copied (written) to the CD using standard Windows operating system features.
  • You may call Myers and Stauffer at (208) 378-1400 if you need help using, saving, printing, or submitting this electronic form.
  • A notes and comments section has been provided on page 14 of the form. Please use this section if you would like to include additional information for any question where space has not already been given. Please remember to include an “Index/Question” reference for each entry on the page.

Version 2015-01