The PCI Security Standards Council makes copies of the various Report of Compliance (ROC) reporting template available to download as a PDF in their Document Library.
The direct link to download the version 4 ROC reporting template is:
If you would prefer a copy of the template in Word format, ask your QSA. They work from the Word version, and should be able to provide you with a copy for review.
The PCI Security Standards Council also have multiple AOC reporting templates available for different kinds of organization.