Attachment_E_Inspection_and_Acceptance_Form.xlsx
XLSX spreadsheet 16 KB Posted
- Attached to
- Protected Health Information Management Services Federal contract opportunity
- Solicitation number
- 19AQMM19R0156
About this file
This document contains a receipt, inspection, and acceptance form template for use on fixed-price task orders, as well as examples demonstrating its application. The template is to be used by the Contracting Officer's Representative to certify receipt, inspection, and acceptance or rejection of deliverables. Examples show the form's use for acceptance of facilities maintenance and landscaping services at percentages less than 100% due to partial completion, as well as rejection and reperformance for an incorrect generator supply. The form requires documentation of deliverable descriptions, quantities, receipt and inspection dates, acceptance or non-acceptance decisions, applicable value determinations, and signatures. It aims to certify inspection and acceptance or rejection of fixed-price deliverables in accordance with FAR requirements for such orders.
This federal contract opportunity notice is for Protected Health Information Management Services to support the Department of State's Bureau of Medical Services. The solicitation will be for an IDIQ contract with a base period of five years and five one-year options to provide receipt, processing, archival, retrieval and transmission services for employee medical records. Tasks may include physical and electronic records management, IT services, security, and training. The contract type for task orders will be one of those in FAR Part 16. The opportunity is a 100% small business set-aside and one award is anticipated. The pre-solicitation notice provides relevant details on requirements, period of performance, and instructions for responding to the forthcoming solicitation.
Attachment E - Inspection and Acceptance Form
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Text version
Fixed-Price Form Bureau of Political Military Affairs (Contract Name) (Contractor Name) IDIQ Contract Number ____________ Task Order Number ____________
Receipt, Inspection, and Acceptance Form For the Billing Period of XX through XX 2019
| This form (or similar form) shall be used for fixed-price task orders and delivery orders. See FAR 52.246-2 (Inspection of Supplies—Fixed-Price) and FAR 52.246-4 (Inspection of Services—Fixed-Price). | |||||||
| IDIQ Contract Reference | Description of Requirement | Task Order/Delivery Order Reference | Description of Requirement | Quantity | Unit of Measurement (select from drop-down) | Received By | |
| (sign or initial) | Received Date | ||||||
| Inspected by (sign or initial) | Inspection Date | Requirement Value | |||||
| (estimated portion of billing period's negotiated fixed price) | Acceptance/ | ||||||
| Non-Acceptance Decision (select from drop-down) | Acceptance/ | ||||||
| Non-Acceptance by (sign or initial) | Acceptance/ | ||||||
| Non-Acceptance Date | Acceptance Percentage | Acceptance Value | |||||
| (K x O) | Justification for | ||||||
| Non-Acceptance | Reperformance/Correction Required | ||||||
| (select from dropdown) | Justification for Requiring Reperformance/Correction | Reperformance/Correction Performed | |||||
| (select from dropdown) | Reperformance/Correction Acceptance Percentage | Reperformance/Correction Acceptance Value | |||||
| (P x U) | Total Acceptance Value | ||||||
| (P + V) | Justification for Final Acceptance |
| EXAMPLES ONLY C.2 | Services: Facilities Maintenance | 1.2 | Facilities Maintenance Labor: Maintain cleanliness of 5,000 square feet facility. | 1 | Month | 7/31/18 | 7/31/18 | $ 10,000.00 | Partially Accepted | 7/31/18 | 80% | $ 8,000.00 | Only 4,000 of the required 5,000 square feet (80%) was kept clean. The performance period to clean the remaining 1,000 square feet has passed, so reperformance cannot occur. Because the contractor did not perform 20% of the requirement, we deducted 20% of the Requirement Value, per FAR 52.232-1. | No | N/A | N/A | 0% | $ - 0 | $ 8,000.00 | N/A |
| EXAMPLES ONLY C.3 | Services: Landscaping | 1.3 | Landscaping Labor: Plant 10 pine trees on building grounds, and each can be no closer than 20 feet from one another. | 1 | Month | 7/31/18 | 7/31/18 | $ 10,000.00 | Partially Accepted | 7/31/18 | 50% | $ 5,000.00 | Five of the required 10 pine trees (50%) were planted properly. An additional three of the 10 (30%) were planted within 20 feet of one another. The final two of the 10 (20%) were not planted at all. Because the contractor did not perform (successfully) 50% of the requirement, we deducted 50% of the Requirement Value, per FAR 52.232-1. | Yes | The required performance schedule permits reperformance that meets the requirement. | Yes | 100% | $ 5,000.00 | $ 10,000.00 | The contractor planted successfully the prior five nonconforming trees, the last of which was received on 8/20/2018 by _____. Such date falls within the required performance schedule. These five remaining trees were inspected on 8/22/2018 by _____, and accepted on 8/23/2018 by ______. Reperformance is allowable but at no increase in task order price, pursuant to FAR 52.246-4(e). |
| EXAMPLES ONLY C.4 | Supplies | 1.4 | Generator: 240 volts, three phase power, 60 Hz frequency | 1 | Each | 7/5/18 | 7/6/18 | $ 3,000.00 | Not Accepted | 7/9/18 | 0% | $ - 0 | The received generator did not meet the requirement. The received generator was only 120 volts, single phase power, and 50 Hz frequency, each of which was below the respective required amount. Because the contractor did not deliver the requirement, we deducted 100% of the Requirement Value, per FAR 52.232-1. | Yes | The required delivery schedule permits replacement to a generator that meets the requirement. | Yes | 100% | $ - 0 | $ - 0 | A generator that meets the requirement was received on 7/20/2018 by _____. Such date falls within the required delivery schedule. The generator was inspected on 7/24/2018 by _____, and accepted on 7/24/2018 by ______. Correction is allowable but at no increase in task order price, pursuant to FAR 52.246-2(g). |
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I certify that the above information is correct.
Contracting Officer’s Representative's (COR's) Signature Date
Print COR Name and Title Here
COR Mailing Address, E-mail Address, and Telephone Number
Note: If the Contractor fails to promptly remove, replace, or correct rejected supplies that are required to be removed or to be replaced or corrected, or if the Contractor fails to promptly perform the services again or to take the necessary action to ensure future performance is in conformity with contract requirements, the COR shall notify promptly the Contracting Officer so that the Contracting Officer can consider to take the steps described in FAR 52.246-2(h), FAR 52.246-2(h) (Alternate I), FAR 52.246-2(h) (Alternate II), or FAR 52.246-4(f), as applicable.
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