MONITOR OUTAGE TABLE

FORM D

Monitor Outage Incident Number Date Time - Beginning
(24 Hour Clock)		 Time - Ending
(24 Hour Clock)		 Hours Involved Cause Code
(Attach Explanation for Codes)		 Corrective Action Code
(Attach Explanation for Codes)

Total duration of monitor downtime .
(This total should equal the time entered on the Form B, CMS Performance Summary, Item II.)