47PB0020R0050 Exhibit 03 Surveillance Forms.docx

Exhibit 03 – Surveillance Forms The following forms are examples of the surveillance forms that will be used in the inspection and monitoring of the contract. Blank Forms shall be provided upon award.

GSA Form 1181A – Contract Cleaning Inspection Report This form shall be filled out and submitted to the Contractor when deficiencies are found during the COR's inspections.

This form can be found at: GSA Insite/Financial Transactions/GSA Forms Library

CONTRACT CLEANING INSPECTION REPORT

INSTRUCTIONS: Form is used for inspection of contract cleaning by inspectors to record results. The condition of area(s) inspected will be rated SATISFACTORY or UNSATISFACTORY. Explain unsatisfactory rating in remarks column and complete quantity column.

INSPECTOR (Print Name) INSPECTOR'S SIGNATURE

JOHN DOE

(Room No., Corridor, lobby, or either) SAT. UNSAT.

By Measure or count .

3rd Floor East

Women's Public Restroom X Men's Public Restroom

-1st near room 1-5566

GENERAL SERVICES ADMINISTRATION GSA FORM 1181A

Quality Deficiency Notice This form shall be filled out and submitted to the contractor when deficiencies are found during the COR’s inspections.

QUALITY DEFICIENCY NOTICE

NAME OF CONTRACTOR CONTRACTOR ADDRESS

XXXX Cleaning Services 333 Smith St. Ste. 201 San Francisco, CA 94102

CONTRACT NO. GS-09P-06-KSD-0000

A deficiency exists in your quality control system. The nature of the deficiency is Continuous findings on 3rd floor men's restroom (M) 3-5171-Rust on toilet base under bolt of toilet. Rust needs to be removed and base needs to be cleaned.

Immediate action is required to correct the deficiency and the condition that caused it. Failure to take acceptable corrective action on time may result in termination of your right to proceed with this contract.

Please provide a written response of corrective action taken to the CO or their designee within _______ workdays after receiving this notice.

EVALUATION OF CORRECTION ACTION

□ Corrective action verified and found acceptable

□ Corrective action not acceptable and /or not implemented (Explain below) This matter is being referred to the Contracting Officer for action. Direct further correspondence on this matter to the CO.

QAS SIGNATURE DATE

RECEIPT ACKNOWLEDGED DATE

QASP Monthly Inspection Report BUILDING NAME & LOCATION: Phillip Burton Federal Building & US Courthouse

CONTRACT NO.:

CONTRACTOR NAME:

Please report all deficiencies found during the previous month inspection(s). Attach copies of all GSA 3539 Forms submitted to the contractor with this form. If there were no deficiencies, please submit this form indicating there were no deficiencies reported for the month. This form will become a part of the official QA documentation.

COR

Signature: _________________ Date: _________________

COR’s Checklist for Inspections

Submittals:

-a list of names and telephone numbers of on-site supervisors -security clearance documentation SAMPLE

(current & new employees)

- work schedules

- floor maintenance schedules

- SDS documentation

- initial IPM inspection report

Quality Control Plan (QCP)

- description of training programs

- description of disciplinary procedures

- description of contingency plan for separation of employees

Inspection Reports

Service Call Logs

Tenant Reports

Integrated Pest Management (IPM) Quarterly Reports

Recycling and Solid Waste/Trash Hauling Reports

NOTE: This checklist does NOT represent an all-inclusive list of items that may be reviewed during an inspection. It is provide ONLY as guidance for the CO or their designee.