2.2 Attachment #4- Report of Survey.pdf
PDF 515 KB Posted
- Attached to
- Resource and Capability Transportation Support during Disasters (RCTSD) Hawaii Islands Federal contract opportunity
- Solicitation number
- 70FB7021R00000004
- Issued by
- Federal Emergency Management Agency
About this file
The document contains a Report of Survey form used by the Federal Emergency Management Agency to document lost, stolen, damaged, or destroyed government property. The form includes blocks to provide details of the incident such as dates, involved parties and their recommendations, findings of a Board of Survey, pecuniary charges and certification by a Budget and Finance Officer. It also contains instructions for completing the form to ensure all necessary information is captured.
A separate document provides a synopsis for a solicitation seeking proposals for Resource and Capability Transportation Support during Disasters for the Hawaiian Islands. Services will include port operations and transportation from the continental US to Hawaii, as well as retrograde support. The requirement is for an Indefinite Delivery Indefinite Quantity contract with a one year base period and four one-year option periods to be awarded as firm fixed price task orders as needs are prescribed. Historical loading and discharge locations in the continental US, Hawaii and the Pacific are identified. The solicitation number and points of contact are provided, and the award will be based on best value.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment 1 Hawaii Price CLIN Structure June 21.xlsx | XLSX spreadsheet | |
| 70FB7021R00000004 Amendment 0001 Signed.pdf | ||
| Vendor Questions 2.2. Attachment 8 Question and Answer(FEMA Responses)..xlsx | XLSX spreadsheet | |
| 2.2 Attachment #6-SF-364 Report of Discrepancy.pdf | ||
| 2.2 Attachment #3 QASP - RCTSD Hawaii.pdf | ||
| 2.2 Attachment #1 Hawaii Price CLIN Structure.xlsx | XLSX spreadsheet | |
| 2.2.1 Solicitaion RCTSD- Hawaii 70FB7021R00000004.pdf.pdf | ||
| 2.2. Attachment 7 -ASN Upload Spreadsheet RCTSD Hawaii.xls | XLS spreadsheet | |
| 2.2 Attachment #2 PWS RCTSD-Hawaii 03-10-2021.pdf | ||
| 2.2 Attachment# 5-SF-91 Accident Report Form.pdf | ||
| 2.2. Attachment 8 Question and Answer Template.xlsx | XLSX spreadsheet | |
| Synopsis for Resource and Capability Transportation Support during Disasters RCTSD Hawaii.pdf |
Show all 12
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
REPORT OF SURVEY
1. DATE PREPARED 2. SURVEY CONTROL NUMBER
3. TYPE OF PROPERTY 4. APO'S OR CO'S PRINTED/TYPED NAME AND LOCATION
5. BARCODE & SERIAL NUMBER 6. NOMENCLATURE AND PART NUMBER 7. QUANTITY 8. UNIT PRICE 9. TOTAL
10. DATE AND CIRCUMSTANCES OF LOSS, THEFT, DAMAGE OR DESTRUCTION (with attachments, as needed. To be completed by custodian of the property when the incident occurred.)
11. INDIVIDUAL PROVIDING ABOVE STATEMENT PRINTED/TYPED NAME AND SIGNATURE 12. DATE
13. ACCOUNTABLE PROPERTY OFFICER (APO) PRINTED/TYPED NAME AND SIGNATURE 14. DATE
15. PROPERTY MANAGEMENT OFFICER (PMO) RECOMMENDATION (Check One)
RECOMMEND NO FURTHER ACTION. NO SUSPECTED NEGLIGENCE INVOLVED RECOMMEND FURTHER INVESTIGATION
16. PROPERTY MANAGEMENT OFFICER PRINTED/TYPED NAME AND SIGNATURE 17. DATE
18. FEMA REPORT OF SURVEY PROCESSING OFFICER
RECOMMEND BOARD OF SURVEY
RECOMMEND FURTHER INVESTIGATION DOCUMENT NOT COMPLETE (Details Attached) RETURN TO PMO
19. FEMA REPORT OF SURVEY PROCESSING OFFICER PRINTED/TYPED NAME AND SIGNATURE 20. DATE
CONCUR WITH PMO RECOMMENDATION
21. FEMA AGENCY PROPERTY MANAGEMENT OFFICER (APMO) REVIEW
ACCEPT/CONCUR WITH RSPO RECOMMENDATIONS
OTHER
(See Attached)
APPOINT BOARD OF SURVEY
FEMA Form 119-7-1-1 MAY 09 PREVIOUSLY FEMA Form 61-5
27. BOARD OF SURVEY CHAIR PRINTED/TYPED NAME AND SIGNATURE
23. OFFICE (Symbol)22. BOARD OF SURVEY OFFICIAL PRINTED/TYPED NAME AND SIGNATURE 24. DATE
25. BOARD OF SURVEY FINDINGS AND RECOMMENDATIONS (with attachments, as needed)
28. DATE
OFFICE OF CHIEF COUNSEL REPRESENTATIVE PRINTED/TYPED NAME AND SIGNATURE 30. DATE
31. COMMENTS (with attachments, as needed)
33. FEMA AGENCY PROPERTY MANAGEMENT OFFICER PRINTED/TYPED NAME AND SIGNATURE 34. DATE
26a. Actual Loss
RECOMMEND PECUNIARY CHARGE
26b. Amount Recommended 26c. Potential Loss To Government
Page 2 of 4FEMA Form 119-7-1-1, MAY 09
32. FINAL PECUNIARY CHARGES
32a. Actual Loss 32b. Amount Charged 32c. Loss To Government
29. OFFICE OF CHIEF COUNSEL
CONCUR WITH ALL FINDINGS SEE ATTACHED OCC FINDINGS AND RECOMMENDATIONS
PREVIOUSLY FEMA Form 61-5
ADJUST SYSTEM OF RECORD ACCORDING TO APMO INSTRUCTIONS
This properly executed and completed form will negate the need of Form 119-7-1-4.
Once this form is ultimately signed by the APMO, it shall be forwarded to the appropriate finance officer to allow collection of pecuniary charges, if applicable, and to the sending APO and PMO.
35. BUDGET AND FINANCE OFFICER PRINTED/TYPED NAME AND SIGNATURE 36. DATE
I hereby certify that the sum of has been billed for the property for which the employee has been held financially responsible, and that immediate steps will be taken toward collection. I certify that the necessary entries have been made to adjust the accounting records.
BUDGET AND FINANCE OFFICER'S CERTIFICATE
INSTRUCTIONS FOR THE PREPARATION OF THE FEMA REPORT OF SURVEY
Block 1, Date Prepared: The date the report is prepared. This date shall be as soon as the item(s) are reported, missing, stolen, damaged or destroyed.
Block 2, Survey Control Number: This is the identification number for the Report of Survey and is assigned by the FEMA Report of Survey Processing Office (RSPO). Obtain this number from the APMO or RSPO prior to submitting the document for processing.
Block 3, Type of Property: The type of property being reported i.e. Computer, Furniture, Sensitive, Various.
Block 4, APO's or CO's Name, as applicable and location: APO or CO Name and Office Location of incident.
Block 5, Barcode and Serial Number: Obtained from item and/or 119-7-1-3 (Custody Receipt), as applicable, and verified in the accountable property management system.
Block 6, Nomenclature and Part Number: Obtained from the accountable property management system of record.
Block 7, Quantity: The number of each type of material being reported.
Block 8, Unit Price: The acquisition price of a single item from the line. Obtained from the accountable property system of record.
Block 9, Total: This is the total cost for all items on that line. Multiply information in Block 7 and Block 8, i.e., the quantity multiplied by the cost of a single item.
Block 10, Date and Circumstance of Loss, Theft, Damage or Destruction: This shall be a full explanation of the circumstances or events that caused the loss, theft, damage or destruction of property. If there are statements, security reports, police reports, etc. these shall be attached as well as any relevant documents and custody receipts. This block shall be filled out by the individual involved, using their own words.
Block 11, Name and Signature of Individual providing statement in Block 10: This certifies that the individual acknowledges that the statement provided is in his/her own words.
Block 12, Date: Date the individual providing the statement completes his/her portion and signs the form.
Block 13, Name and Signature of APO: The APO name shall be clearly printed/typed in the block and the APO will sign in the block.
Block 14, Date: Date the APO completes his/her portion and signs the form.
Block 15, PMO Recommendation: The PMO makes his/her recommendation by checking the appropriate block and shall forward the original Report of Survey to the Central Processing Center, FEMA APMO. The PMO will retain a copy of this report until final disposition is made.
Block 16,Name and Signature of PMO: The PMO name shall be clearly printed/typed in the block and the PMO will sign in the block.
Block 17, Date: Date the PMO checks the appropriate selection in box 15 and signs the form.
Block 18, FEMA Report of Survey Processing Officer: Upon receipt of the Report of Survey packet, the Report of Survey Processing Officer reviews the information provided and checks the appropriate block.
Block 19, FEMA Name and Signature of the Report of Survey Processing Officer: The FEMA Report of Survey Processing Officer name shall be clearly printed/typed in the block, and the Report of Survey Processing Officer will sign in the block.
Block 20, Date: Date the Report of Survey Processing Officer checks the appropriate selection in Block 18 and signs the form.
Block 21, FEMA Agency Property Management Officer Review: This block is used to establish a Board of Survey, accept or concur with Report of Survey Processing Officer or make appropriate recommendations.
Block 22, Board of Survey Official: The Board of Survey Official's name shall be clearly printed/typed in the block, and the Board of Survey Official will sign in the block.
Block 23, Office (Symbol): The office symbol of the individual in Block 22.
Block 24, Date: The date the Board of Survey Official is appointed and signs the form.
Block 25, Board of Survey Recommendations: Used to document Board of Survey findings and recommendations.
Block 26, Recommended Pecuniary Charge: Used to identify amount of loss and suggested financial liability. If the report has several line items, each item must be individually listed on an attachment and the total amount will be shown on the following lines.
26a Actual Loss - Item acquisition cost from the accountable property management system of record.
26b Amount Recommended - Fair market value of the item(s) on this Report of Survey.
26c Potential Loss to Government - Subtract amount in 26b from amount in 26a.
Block 27, Name and Signature of Board of Survey Chair: The Board of Survey Chair name shall be clearly printed/typed in the block, and the Board of Survey Chair will sign in the block.
Block 28, Date: Date the Board of Survey Chair signs the form.
Block 29, Office of Chief Counsel: The Office of Chief Counsel representative's name shall be clearly printed/typed in the block, and the Office of Chief Counsel representative will check the appropriate box and sign in the block.
Block 30, Date: Date the Office of Chief Counsel representative checks the appropriate selection in Block 29 and signs the form.
Block 31, Comments: Use to document any additional comments from Office of Chief Counsel, APMO or Central Processing Reviewing Officer as needed.
Block 32, FINAL Pecuniary Charges: Used to document financial liability for lost, stolen, damaged or destroyed items. If the report has several line items, each item must be individually listed on an attachment and the total amount will be shown on the following lines.
32a. Actual Loss - Item acquisition cost from the accountable property management system of record.
32b. Amount Charged - Fair market value of the item(s) on this Report of Survey. The amount charged may differ from the fair market value depending on recommendations from the Board of Survey Chair, Report of Survey Officer, OCC or APMO. An attachment with detailed explanation and justification must be provided by the person not accepting fair market value as the pecuniary charge, for each item.
32c. Loss to Government - Subtract amount in 32b from amount in 32a.
Page 3 of 4PREVIOUSLY FEMA Form 61-5FEMA Form 119-7-1-1, MAY 09
INSTRUCTIONS FOR THE PREPARATION OF THE FEMA REPORT OF SURVEY - continued
Block 33, FEMA Agency Property Management Officer Signature (APMO): The APMO name shall be clearly printed/typed in the block and the APMO will sign in the block.
Block 34, Date: Date the FEMA APMO signs the form.
Block 35, Budget and Finance Officer Signature (BFO): The BFO name shall be clearly printed/typed in the block and the BFO will sign in the block.
Block 36, Date: Date the FEMA BFO signs the form.
Page 4 of 4PREVIOUSLY FEMA Form 61-5FEMA Form 119-7-1-1, MAY 09
DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
REPORT OF SURVEY
5. BARCODE & SERIAL NUMBER
6. NOMENCLATURE AND PART NUMBER
7. QUANTITY
8. UNIT PRICE
9. TOTAL
15. PROPERTY MANAGEMENT OFFICER (PMO) RECOMMENDATION (Check One)
18. FEMA REPORT OF SURVEY PROCESSING OFFICER
21. FEMA AGENCY PROPERTY MANAGEMENT OFFICER (APMO) REVIEW
FEMA Form 119-7-1-1 MAY 09 PREVIOUSLY FEMA Form 61-5 FEMA Form 119-7-1-1, MAY 09
32. FINAL PECUNIARY CHARGES
29. OFFICE OF CHIEF COUNSEL
PREVIOUSLY FEMA Form 61-5
ADJUST SYSTEM OF RECORD ACCORDING TO APMO INSTRUCTIONS
This properly executed and completed form will negate the need of Form 119-7-1-4.
Once this form is ultimately signed by the APMO, it shall be forwarded to the appropriate finance officer to allow collection of pecuniary charges, if applicable, and to the sending APO and PMO.
I hereby certify that the sum of has been billed for the property for which the employee has been held financially responsible, and that immediate steps will be taken toward collection. I certify that the necessary entries have been made to adjust the accounting records.
BUDGET AND FINANCE OFFICER'S CERTIFICATE
INSTRUCTIONS FOR THE PREPARATION OF THE FEMA REPORT OF SURVEY
Block 1, Date Prepared: The date the report is prepared. This date shall be as soon as the item(s) are reported, missing, stolen, damaged or destroyed.
Block 2, Survey Control Number: This is the identification number for the Report of Survey and is assigned by the FEMA Report of Survey Processing Office (RSPO). Obtain this number from the APMO or RSPO prior to submitting the document for processing.
Block 3, Type of Property: The type of property being reported i.e. Computer, Furniture, Sensitive, Various.
Block 4, APO's or CO's Name, as applicable and location: APO or CO Name and Office Location of incident.
Block 5, Barcode and Serial Number: Obtained from item and/or 119-7-1-3 (Custody Receipt), as applicable, and verified in the accountable property management system.
Block 6, Nomenclature and Part Number: Obtained from the accountable property management system of record.
Block 7, Quantity: The number of each type of material being reported.
Block 8, Unit Price: The acquisition price of a single item from the line. Obtained from the accountable property system of record.
Block 9, Total: This is the total cost for all items on that line. Multiply information in Block 7 and Block 8, i.e., the quantity multiplied by the cost of a single item.
Block 10, Date and Circumstance of Loss, Theft, Damage or Destruction: This shall be a full explanation of the circumstances or events that caused the loss, theft, damage or destruction of property. If there are statements, security reports, police reports, etc. these shall be attached as well as any relevant documents and custody receipts. This block shall be filled out by the individual involved, using their own words.
Block 11, Name and Signature of Individual providing statement in Block 10: This certifies that the individual acknowledges that the statement provided is in his/her own words.
Block 12, Date: Date the individual providing the statement completes his/her portion and signs the form.
Block 13, Name and Signature of APO: The APO name shall be clearly printed/typed in the block and the APO will sign in the block.
Block 14, Date: Date the APO completes his/her portion and signs the form.
Block 15, PMO Recommendation: The PMO makes his/her recommendation by checking the appropriate block and shall forward the original Report of Survey to the Central Processing Center, FEMA APMO. The PMO will retain a copy of this report until final disposition is made.
Block 16,Name and Signature of PMO: The PMO name shall be clearly printed/typed in the block and the PMO will sign in the block.
Block 17, Date: Date the PMO checks the appropriate selection in box 15 and signs the form.
Block 18, FEMA Report of Survey Processing Officer: Upon receipt of the Report of Survey packet, the Report of Survey Processing Officer reviews the information provided and checks the appropriate block.
Block 19, FEMA Name and Signature of the Report of Survey Processing Officer: The FEMA Report of Survey Processing Officer name shall be clearly printed/typed in the block, and the Report of Survey Processing Officer will sign in the block.
Block 20, Date: Date the Report of Survey Processing Officer checks the appropriate selection in Block 18 and signs the form.
Block 21, FEMA Agency Property Management Officer Review: This block is used to establish a Board of Survey, accept or concur with Report of Survey Processing Officer or make appropriate recommendations.
Block 22, Board of Survey Official: The Board of Survey Official's name shall be clearly printed/typed in the block, and the Board of Survey Official will sign in the block.
Block 23, Office (Symbol): The office symbol of the individual in Block 22.
Block 24, Date: The date the Board of Survey Official is appointed and signs the form.
Block 25, Board of Survey Recommendations: Used to document Board of Survey findings and recommendations.
Block 26, Recommended Pecuniary Charge: Used to identify amount of loss and suggested financial liability. If the report has several line items, each item must be individually listed on an attachment and the total amount will be shown on the following lines.
26a Actual Loss - Item acquisition cost from the accountable property management system of record.
26b Amount Recommended - Fair market value of the item(s) on this Report of Survey.
26c Potential Loss to Government - Subtract amount in 26b from amount in 26a.
Block 27, Name and Signature of Board of Survey Chair: The Board of Survey Chair name shall be clearly printed/typed in the block, and the Board of Survey Chair will sign in the block.
Block 28, Date: Date the Board of Survey Chair signs the form.
Block 29, Office of Chief Counsel: The Office of Chief Counsel representative's name shall be clearly printed/typed in the block, and the Office of Chief Counsel representative will check the appropriate box and sign in the block.
Block 30, Date: Date the Office of Chief Counsel representative checks the appropriate selection in Block 29 and signs the form.
Block 31, Comments: Use to document any additional comments from Office of Chief Counsel, APMO or Central Processing Reviewing Officer as needed.
Block 32, FINAL Pecuniary Charges: Used to document financial liability for lost, stolen, damaged or destroyed items. If the report has several line items, each item must be individually listed on an attachment and the total amount will be shown on the following lines.
32a. Actual Loss - Item acquisition cost from the accountable property management system of record.
32b. Amount Charged - Fair market value of the item(s) on this Report of Survey. The amount charged may differ from the fair market value depending on recommendations from the Board of Survey Chair, Report of Survey Officer, OCC or APMO. An attachment with detailed explanation and justification must be provided by the person not accepting fair market value as the pecuniary charge, for each item.
32c. Loss to Government - Subtract amount in 32b from amount in 32a.
PREVIOUSLY FEMA Form 61-5 FEMA Form 119-7-1-1, MAY 09
INSTRUCTIONS FOR THE PREPARATION OF THE FEMA REPORT OF SURVEY - continued
Block 33, FEMA Agency Property Management Officer Signature (APMO): The APMO name shall be clearly printed/typed in the block and the APMO will sign in the block.
Block 34, Date: Date the FEMA APMO signs the form.
Block 35, Budget and Finance Officer Signature (BFO): The BFO name shall be clearly printed/typed in the block and the BFO will sign in the block.
Block 36, Date: Date the FEMA BFO signs the form.
PREVIOUSLY FEMA Form 61-5 FEMA Form 119-7-1-1, MAY 09 Luis E. Morales Property Form is used in conjunction with 6150.1, Personal Property which details the use of Government Poropert on Personal Loan. Formerly Form 61-5 and 123-3-1-1.
Luis E. Morales Report of Survey
MAY 09
| Date Report is prepared. Date should be as soon as the items are reported missing or damaged.: |
| Budget and Finance Officers Printed or Typed Name and Signature.: |
| Date of individuals signature.: |
| Date of Accountable Property Officers signature.: |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| If the Property Management Officer recommends Appoint Board of Survey, check here.: 0 |
| Date of Property Management Officers signature.: |
| Date of Budget and Finance Officers Signature.: |
| Final Pecuniary Charges. Actual Loss. Enter the acquisition value of the loss.: |
| If review of, O, G, C, findings and recommendations is required, check here.: 0 |
| If review of, O, G, C, findings and recommendations is required, check here.: 0 |
| If review of, O, G, C, findings and recommendations is required, check here.: 0 |
File details come from the government source that posted it. Updated .