36C24518R0243-003.docx

ATTACHMENT 2: QUALITY ASSURANCE

MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint LEVEL OF SURVEILLANCE (Check):

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________

Contract Discrepancy Report (Attachment 3)

Contract No.

Report No. for this Discrepancy:

Contractor/Manager’s Name:

From: (Name of Project Officer)

Dates

Prepared:

Returned by Contractor:

Action Complete:

Discrepancy or Problem:

Signature of Contracting Officer:

To: (Contracting Officer)

From: (Contractor)

Contractor Response as to Cause, Corrective Action and Actions to Prevent Recurrence (Attach Continuation Sheet if Necessary)

Signature of Contractor Representative:

Date:

Government Evaluation:

Government Actions:

Close Out

Contractor Notified

Project Officer

Contracting Officer