Item 1. From (Originating point). The originating point enters their address in block 1a, the name, duty phone, and signature of an individual who can serve as a contact for questions regarding the report in block 1b, and the date the report was signed and forwarded to the screening or action point in block 1c.

Item 2. To (Screening point). The originating point will complete the name of screening point activity, the activity address code, address including zip code of the screening point where the report needs to be sent by the originator's activity in block 2a, the name, telephone number and signature of the individual who may serve as the screening point's point of contact in block 2b, and the date the person finished processing the report at the screening point in block 2c.

Figure 5-5.-Sample Category II Quality Deficiency Report (CAT II QDR), Standard Form (SF) 368 (Front). 5 Continue Reading