Texas Health and Human Services
SAH 21-1, Appendix II
On-Site Security Review
Local/Benefit Office Address: Review Date:
EBT Site Coordinator: Last Review:
EBT Site Coordinator Backup: Reviewer:
Program Manager: Review Months:
Office Security Procedures
[Reference in brackets] Yes No N/A If no, explanation or comments
1. Did the local benefit office follow Electronic Benefit
Transfer (EBT) procedures, including regional
procedures?
2. Was the Local Office Security Plan (LOSP) updated
to reflect current staff and permissions?
3. Were EBT permissions for staff listed on the LOSP
consistent with the level of access of their assigned
position in EBT?
4. Was there a current contingency plan and location
for EBT issuance in the LOSP?
5. Are staff aware of special procedures for home-visit
advisors who handle Lone Star cards and are they
being followed? [Form H1172, EBT Card, PIN and
Data Entry Request, and Form H1173, EBT Card
Issuance and PIN Self-Selection/Issuance Log,
Instructions, Texas Works Handbook (TWH) B-233]
6. Were special EBT Issuance procedures for home-
visits followed? [Form H1172 and Form H1173
Instructions, TWH B-233]
7. Were separation of duties for ordering, receiving,
storing, issuing and accounting for Lone Star Cards
followed?
Texas Health and Human Services
SAH 21-1, Appendix II
Physical and Data Security Yes No N/A If no, explanation or comments
8. Was there documentation indicating Lone Star
Cards were physically counted upon receipt?
9. Were the security procedures followed on how to
secure Lone Star Cards after a physical inventory?
10. Did EBT clerks secure daily (working) supply in a
locked file cabinet, drawer or safe overnight?
11. Did EBT clerks lock the daily (working) supply when
leaving their workstations?
12. Were keys to EBT supply (bulk or daily) file cabinets
and safes kept secured?
13. Were security procedures for access to the EBT
system or EBT card supplies followed correctly?
14. Did the number of cards for the daily (working)
supply conform to the LOSP for overnight storage?
15. Was a periodic physical inventory of unused Lone
Star Cards completed during the day, week or
month?
16. Was the EBT clerk's computer placed so that
customers passing by cannot see monitor screens?
17. Did EBT staff sign off when leaving their
workstations?
Texas Health and Human Services
SAH 21-1, Appendix II
Record Control Yes No N/A If no, explanation or comments
18. Was a signed receipt or documentation of the
delivery of secure Lone Star cards submitted to the
EBT regional coordinator within five days of receipt?
19. Was Form H1177, Transmittal and Receipt for
Controlled EBT Documents, used when transferring
Lone Star Cards?
20. Was Form H1177 completed properly?
21. Were Lone Star Cards given to the EBT clerks in
approved increments with Form H1173, EBT Card
Issuance and PIN Self-Selection/Issuance Log,
having PANs listed on it?
22. Was there a Void/Return Log completed for voided/
returned Lone Star Cards?
23. Was the Void/Return Log completed properly?
24. Were voided/returned Lone Star Cards immediately
deactivated on the EBT system?
25. Were the Lone Star Cards issued in sequential
order?
26. Did the EBT clerk check each customer’s or their
representative’s ID when issuing Lone Star Cards?
27. Did the EBT clerk obtain the customer’s or their
representative’s signature on Form H1173 when
issuing Lone Star Cards?
Texas Health and Human Services
SAH 21-1, Appendix II
Record Control Yes No N/A If no, explanation or comments
28. Was Form H1173 completed for all in-office
issuances?
29. Was Form H1173 completed correctly?
30. Was Form H1172, EBT Card, PIN and Data Entry
Request, and/or TIERS EBT Issuance Request
completed in the office and for home visits?
31. Was Form H1172 and/or TIERS EBT Issuance
Request completed correctly in the office and for
home visits?
32. Did the EBT site coordinator prepare Form H1174,
Inventory of EBT Cards/PIN Packets? [Form H1174
Instructions]
33. Did EBT site coordinator properly complete Form
H1174 and submit it timely for Lone Star Cards?
[Form H1174 Instructions]
EBT System and TIERS Yes No N/A If no, explanation or comments
34. Is the separation of duties for EBT and Texas
Integrated Eligibility Redesign System (TIERS)
acceptable?
35. Was the EBTDS303-1 report printed daily, including
weekends and holidays?
36. Was the EBTDS303-1 report reconciled daily with
Forms H1172 (if needed), DG061, H1173, H1175,
Void/Return Log and was it signed and dated by the
EBT site coordinator or their designee to validate
reconciliation?
37. Was Form H1172 and/or TIERS EBT Issuance
Request completed correctly in the office and for
home visits?
Texas Health and Human Services
SAH 21-1, Appendix II
EBT System and TIERS Yes No N/A If no, explanation or comments
38. Did the EBT site coordinator prepare Form H1174,
Inventory of EBT Cards/PIN Packets? [Form H1174
Instructions]
39. Were discrepancies found during the EBT report
reconciliation or EBT issuance process resolved on
the same day or not later than three workdays?
40. Was the EBT request completed on TIERS or Form
H1172 submitted to the EBT clerk before requesting
or issuing a Lone Star Card on the EBT system and
when a Lone Star Card is given to an individual
during a home visit?
41. Was Form H1172 signed and dated and/or TIERS
Electronic EBT request completed by the EBT clerk?
42. Was Form H1175, EBT Change Request,
completed?
43. Was Form H1175 completed correctly? [Form
H1175 Instructions]
44. Did EBT staff ask for HHSC identification of the EBT
regional coordinator prior to audit review?
45. Were manual issuance procedures followed while
authorizing benefits in the EBT system when TIERS
was unavailable?
46. Was the Eligibility Determination Group (EDG)
processed in TIERS within three days after
authorizing benefits through the EBT system?
47. Was the EBT report reconciled with Form H1175
entries and/or TIERS inquiry when benefits were
issued on the EBT system?
48. Was Form H1175 submitted to the responsible EBT
issuing staff when authorizing benefits through the
EBT system?