ATCH-2 Quality Assurance Survellience Plan.pdf

US Department of Agriculture (USDA)

Quality Assurance Surveillance Plan (QASP)

Roadway Maintenance Service for the Umatilla National Forest

Solicitation 1240BE24Q0114

Contents Project Name Solicitation / Contract Number Section 1: Introduction

1.1 Purpose

1.2 QASP Relation to the Contract

1.2.1 QASP Revisions

1.2.2 Surveillance of Performance Progression

1.3 QASP Relation to the Quality Control Plan (QCP)

Section 2: Performance Description

2.1 Performance Standards and Acceptable Quality Levels (AQLs)

2.1.1 Allowable Deviation

2.1.2 Substantially Complete

2.2 Non-Performance

2.2.1 Documentation

2.2.2 Remedial Actions

Section 3: Contractor and Government Responsibilities

3.1 Contractor Responsibility

3.2 Government Responsibility

3.2.1 Contracting Officer (CO)

3.2.2 Contracting Officer Representative (COR)

3.2.3 Customers

Section 4: Surveillance Methods to Perform Quality Assurance

4.1 Surveillance Methods

4.2 Analysis and Results

4.3 Evaluation Criteria………………………………………………………………………………………………………….…..6 Appendix A: Maintenance Standards and Quality Levels - Specifications 811, 832, 834 Appendix B: Example Daily Diary Appendix C: Customer Feedback Record

Project Name North Zone Road Surface Maintenance (blading), South Zone Road Drainage Activities (cleaning ditches, culverts etc)

Solicitation / Contract Number 1240BE24Q0114 / Contract Number TBA

Section 1: Introduction This Quality Assurance Surveillance Plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) Roadside Maintenance Service for the Umatilla National Forest. The Umatilla National Forest requires road surface maintenance service on Forest Service roads in the Umatilla NF. Mileage for road maintenance (811) is estimated at 104.5 miles. Specific performance tasks are listed in PWS Paragraph 3.

This plan sets forth the procedures and guidelines that the USDA, Umatilla National Forest will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

The purpose of the QASP is to describe the systematic methods used to measure performance and to identify the reports required and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards identified in the Performance Work Statement, PWS. This QASP is designed to define roles and responsibilities, identify the performance objectives, define the methodologies used to monitor and evaluate the contractor’s performance, describe quality assurance reporting, and describe the analysis of quality assurance monitoring results.

1.2 QASP Relation to the Contract

1.2.1 QASP Revisions

The Contracting Officer Representative (COR) may make revisions or changes to the QASP procedures and surveillance methods or increase or decrease the degree of surveillance methods at any time during the contract performance period.

Changes to the Metric must be incorporated into the PWS, Performance Requirement Summary (PRS) and QASP by a bilateral modification to contract that is issued by the Contracting Officer (CO). A copy of the QASP is provided to the contractor to enable the contractor to enhance its Quality Control (QC) program to perform in accordance with its Quality Control Plan (QCP).

1.2.2 Surveillance of Performance Progression

As the performance period progresses, the levels of surveillance may be altered for service areas where performance is either consistently excellent or unsatisfactory. If consistently good performance, then the amount of surveillance may be reduced. If observations reveal consistent deficiencies, increased surveillance may be implemented.

1.3 QASP Relation to the Quality Control Plan (QCP)

The QCP is a required element of contract and the Contractor shall adhere to its established quality control processes and procedures in managing and performing work as described in the contract. While the QCP represents the way in which the Contractor will ensure its quality and timeliness of services, as defined in the PWS, the QASP represents the way in which the Government personnel specified in Section 3: Contractor and Government Responsibilities, Paragraph 3.2, Government Responsibilities will evaluate the contractor’s performance. The contractor’s QC program and the residual organization’s QASP should be complementary programs that ensure successful contractor performance.

Section 2: Performance Description Performance of the contractor will be monitored through the surveillance methods described in Section 4: Surveillance Methods to Perform Quality Assurance to assess the Contractor’s performance against PWS requirements.

2.1 Performance Standards and Acceptable Quality Levels (AQLs) For selected activities in the PWS, the PRS provides a performance standard and an AQL. A performance standard is the expected level of contractor performance. An AQL defines the level of performance that is satisfactory. Depending on the service evaluated and the evaluation method selected, performance standards and AQLs may be stated as a number of occurrences or as a percentage. Performance standards and AQLs for random sampling and 100 percent inspection are generally stated as percentages. For periodic inspections, performance standards may be stated as either percentages or as absolute numbers.

The contract requires the Contractor to perform all work as specified. Any inaccuracies or omissions in services or products are referred to as “defects” on the part of the Contractor. The Contractor shall be responsible for all identified defects and may be required to perform the work at no cost to the government. The AQLs take into account that in some instances an allowable level of deficiencies (deviations) is possible while overall performance continues to meet the government’s desired level of service.

2.1.1 Allowable Deviation

The AQLs define the level or number of performance deficiencies the Contractor is permitted to reach under this contract.

AQLs take into account the difference between an occasional defect and a gross number of defects. AQLs can be expressed as a percentage of or as an absolute number (e.g., three per month). There may be instances where 100 percent compliance is required, and no deviation is acceptable (e.g., where safety is involved).

2.1.2 Substantially Complete

In some cases, service outputs are evaluated using subjective values (e.g., excellent, satisfactory, unsatisfactory). The criteria for acceptable performance and for defects must be defined for these service outputs. The concept of “substantially complete” should be the basis for inspections based on subjective scales. Work is considered “substantially complete” where there has been no significant departure from the terms of the contract and no omission of essential work. In addition, the Contractor has performed the work required to the best of its ability and the only variance consists of minor omissions or deficiencies.

2.2 Non-Performance

Non-performance occurs when the contractor’s performance does not meet the AQL for a given requirement. Requirements may contain multiple performance elements, and therefore, deficiencies may occur in one or more aspects of performance (e.g., timeliness, accuracy, completeness, etc.) or subject areas of effort.

When surveillance indicates that the contractor's service output is not in compliance with the contract requirements, the Contracting Officer’s Representative (COR) must determine whether the Contractor or the Government caused the deficiency.

If the cause of the defect rests with the Government, corrective action must be taken through Government channels. If the cause of the defect is due to action or inaction by the contractor, the contractor is responsible for correction of the problem at no additional expense to the Government.

2.2.1 Documentation

Documentation of work non-performed or unacceptable work is essential for tracking Contractor performance. The COR will document deficient work by compiling facts describing the inspection methods and results and to substantiate nonconformance with the contract. A sample documentation reporting form is provided in Appendix B, Example Discrepancy Report. The documentation, with any recommendations, will be forwarded to the CO. In the case of the Contractor, the COR will decide whether to elevate the problem to the CO for corrective action.

2.2.2 Remedial Actions

The Federal Acquisition Regulation allows for penalties in the event that the Contractor fails to perform the required services.

Penalties are defined as those actions taken under the direction of the CO against the contractor within the general provisions of the contract for nonconformance to the PWS and PRS.

Section 3: Contractor and Government Responsibilities

3.1 Contractor Responsibility

The Contractor is responsible for delivering products or services in accordance with the contract. Implementing its QCP, which describes the Contractor’s methods for ensuring all products and services under the contract meet established performance standards and AQLs. Maintaining, and providing for audit, quality control records and reports and all records associated with the investigation and complaint resolutions. Appointing a single quality control point-of-contact to act as a central recipient of communication from the COR or CO.

3.2 Government Responsibility

3.2.1 Contracting Officer (CO)

The CO is responsible for administering and monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by COR and the contractor’s performance. The CO may delegate various day-to-day contract administration duties to the COR for performance management and administrative actions such as invoice approval and issuance of Contract Discrepancy Reports may be, and normally are, delegated by the CO to the COR. The CO shall approve any revisions to the QASP processes or standards.

3.2.2 Contracting Officer Representative (COR)

The COR, is designated in writing, by the CO. The COR will ensure that the QA function is properly executed, plays a key role in contract administration and performs the contract surveillance and monitoring. Some key contract administration duties include, but are not limited to, performs surveillance as required by this QASP; make recommendations to the CO for issuance of Contract Discrepancy Reports or letters of commendation and acceptance or rejection of completed work and for administrative actions based on unsatisfactory or non-performed work, and revisions or changes to the QASP; and assists the CO in identifying necessary contract modifications and preparing reports of Contractor performance and cost.

The COR may use the form(s) included in the Appendices to perform the inspection or other forms as approved by the CO.

3.2.3 Customers

Customers or organizations/offices that the Contractor provided support may be requested to assist the COR in conducting QA to provide information relating to the Contractor’s performance through Customer Feedback. Information gained from the Customer Feedback may be used in conjunction with other methods of observation to rate the performance of the Contractor.

Section 4: Surveillance Methods to Perform Quality Assurance

4.1 Surveillance Methods

The surveillance methods used in the QA process are the Government’s tools to monitor the Contractor’s products and services. The best means of determining whether the Contractor has met all contract requirements is to inspect the Contractor’s service products and analyze the results. Further, documented inspection results are an effective tool in contract administration that can confirm the successful achievement of all performance requirements or highlight areas where defects exist and improvements are necessary.

4.1.a 100 Percent Inspection The 100 percent inspection method requires complete inspection for each work activity and will be used for critical contract requirements.

4.1.b Performance Standards and AQLs Calculating Acceptable Quality Level, AQL: Acceptable quality levels AQL will be calculated by dividing the number of acceptable occurrences observed by the number of possible occurrences observed. For example: Paragraph 3.2 in month one the COR observed 20 roadway maintenance services. Of the 20 observed services, 18 were satisfactory. 18 satisfactory observations divided by 20 possible observation equals 0.9 or 90%.

4.2 Analysis and Results

When the inspections and validations have been completed, the COR will perform an analysis of the Contractor’s performance. The purpose of the analysis is to ensure Government is receiving high-quality products and services from the Contractor. The COR will review the results, rate the Contractor’s compliance with the performance standards and AQLs, and characterize the Contractor’s overall performance. Analysis of all types of contract monitoring will result in one of the following outcomes:

Performance Rating Criteria

Exceptional

Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Appendix A: Maintenance Standards and Quality Levels

811 – Road Surface Maintenance Passenger Car Roads and High Clearance Roads

Umatilla National Forest (02/09)

811.01

Services Required

Perform maintenance on roadway surfaces to facilitate safe travel on passenger car or high clearance roads.

811.02

Performance Standards

Passenger Car Road Surface Maintenance

Roadway surfaces are maintained to standard when:

• There is adequate moisture present to facilitate cutting to a depth to completely remove washboards and potholes (see note regarding watering in Section 811.05).

• Retrievable suitable materials outside the standard traveled way widths (described below) have been reclaimed and incorporated into the remaining surface course.

• A cutting pass has been made (where adequate crushed aggregate depths exist) over the entire width of the traveled way, including turnouts.

• Shoulders, turnouts, and intersections are free of washboards, potholes, unsuitable materials, or other irregularities.

• There is adequate moisture present to adequately bind the surface materials for compaction by traffic at the time of the spread.

• The surface materials have been spread to the following approximate standard traveled way widths:

o Single Lane Road Segments: Width = 14 Feet, Turnouts = 10 Feet o Double Lane Road Segments: Width = 24 Feet

• Finished surfaces are smooth, uniform, and crowned/sloped to drain.

Requirement for Non-native Invasive Plant Species Control

Prior to entering National Forest lands, all road maintenance equipment shall be cleaned to minimize the potential spread of non-native invasive plant species. Prudent actions, such as washing or using compressed air, shall be taken to clean equipment, prior to moving from one project area to another within the National Forest, to ensure that these species are not spread.

811.03

Location of Work

Work will apply to those road segments shown on the road listings. Work on additional road segments may be ordered by the Contracting Officer.

811.04

Measurement

Measurement will be made of each item or unit of work, as shown in the Schedule of Items, completed and accepted in accordance with the contract provisions, specifications, and drawings.

• Mile - All work under this specification will be measured along the linear centerline of the roadway, and rounded to the nearest tenth (0.1) of a mile.

811.05

Payment

Accepted quantities will be paid at the contract price per unit of measurement for the Section 811 pay items listed in the Schedule of Items. Payment will be full compensation for the work prescribed in this section.

NOTES: Mobilization, removal of obstructions, and watering are incidental to pay items.

Removal of Obstructions - Efforts shall be made to have debris removed from roads prior to commencement of surface maintenance. However, obstructions encountered during surface maintenance activities shall be removed by the contractor in accordance with the Standard Logout Typical.

Watering – This requirement shall be waived if there is not an adequate (readily recoverable) water source within 5 miles of the segment being maintained.

Pay Item Pay Unit

811(02) Road Surface Maintenance Mile Double Lane Passenger Car Roads

811(03) Road Surface Maintenance Mile Single Lane Passenger Car Roads

811.06

Acceptable Quality Levels

Acceptance will be determined by visual inspection. If visual inspection finds that all work conforms to performance standards (811.02), the work will be acceptable. If visual inspection finds that occasional work elements do not completely conform to performance standards, but non-conforming work is not representative of the overall quality of work, the work will be acceptable. If visual inspection finds that non-conforming work is representative of the overall quality of work, rework will be required.

832 – Load, Haul, and Place Materials

Umatilla National Forest (04/10)

832.01

Services Required

Load designated materials, haul to designated sites, and place as required, as shown in this contract or drawings.

832.02

1. Loading, Hauling, and Placement of Materials

Loading, hauling, and placement of materials is complete when:

• all designated materials have been loaded, hauled, and placed as required,

• roughness from the operation has been smoothed and compacted,

• damages to haul routes have been repaired, and

• materials have not been placed to prevent existing drainage systems (ditches and culverts) from functioning properly.

2. Requirement for Non-native Invasive Plant Species Control

Prior to entering National Forest lands, all road maintenance equipment shall be cleaned to minimize the potential spread of non-native invasive plant species. Prudent actions, such as washing or using compressed air, shall be taken to clean equipment, prior to moving from one project area to another within the National Forest, to ensure that these species are not spread.

832.03

Work will apply to those areas shown in this contract or drawings. Additional work may be ordered by the Contracting Officer.

832.04

Measurement

Measurement will be made of each item or unit of work, as shown in the Schedule of Items, completed and accepted in accordance with the contract provisions, specifications, and drawings.

•Cubic Yard: The quantity will be the number of cubic yards measured in the vehicles.

•Mile: Work activities by the mile will be measured along the centerline of the roadway, and rounded to the nearest hundredth of a (0.01) mile.

832.05

Payment

Accepted quantities will be paid at the contract price per unit of measurement for the Section 832 pay items listed in the Schedule of Items. Payment will be full compensation for the work prescribed in this section.

NOTE: Mobilization is incidental to pay items.

Pay Item Pay Unit

832(01) Load, Haul, and Place Materials Cubic Yard

832(02) Load, Haul, and Place Materials Mile

832(03) Load, Haul, and Place Materials Lump Sum

832.06 Acceptable Quality Levels for Loading, Hauling, and Placement of Materials

Description Major Defect Allowable Major Defects

Action Required to Correct Major Defects

Minor Defect Allowable Minor Defects

Action Required to Correct Minor

Defects

Loading

Materials

More than half of a full load of designated materials remaining at loading site

None

Load remaining designated materials

Less than half of a full load of designated materials remaining at loading site

No limit, if corrective actions are taken.

Otherwise, load remaining materials.

Alternatives for loading less than half of a full load of designated material are subject to approval by the COR.

Equipment causing potential damages to asphalt surface

Cease operation immediately if asphalt surface shows evidence of marring, rutting, or other potential damages, and resume loading when surface is stable

Equipment causing potential damages to non-asphalt surfaces

Minor disturbances to aggregate or native surface materials

None, unless more than 2” deep or will compromise roadway drainage. Otherwise, smooth and compact area of disturbance.

Hauling Materials

Damage to haul route caused by haul vehicle

Repair damages

Spilled materials

Reload spilled materials and refrain from loading trucks too full Placing

Materials Materials not placed in designated location

Relocate materials to designated location

Materials placed where they may interfere with existing road drainage systems

Relocate materials away from drainage systems

Materials placed with no regard for aesthetic values

Place materials and shape/finish as required

834 – Roadway Drainage System Maintenance Umatilla National Forest (08/10)

834.01 Services Required

Maintain roadway drainage systems (culverts, ditches, and other drainage structures) to provide effective roadway drainage function.

834.02

Culvert/Ditch/Drainage Structure Cleaning

Culvert/ditch/drainage structure cleaning is complete when:

• obstructions that have the potential to prevent the drainage systems specified for cleaning from functioning properly have been removed and disposed of, as shown on the drawings,

• damages to the template or appurtenances have been repaired (see 834.06), and

• the traveled way has been cleared of residual debris and materials generated by drainage system cleaning, and roughness from the operation has been smoothed and compacted.

Requirement for Non-native Invasive Plant Species Control

Prior to entering National Forest lands, all road maintenance equipment shall be cleaned to minimize the potential spread of non-native invasive plant species. Prudent actions, such as washing or using compressed air, shall be taken to clean equipment, prior to moving from one project area to another within the National Forest, to ensure that these species are not spread.

834.03

Work will apply to those areas shown on the drawings. Additional work may be ordered by the Contracting Officer.

834.04 Measurement

Measurement will be made of each item or unit of work, as shown in the Schedule of Items, completed and accepted in accordance with the contract provisions, specifications, and drawings.

• Each - Work activity will be measured by the actual number of units completed.

• Mile - Work activities by the mile will be measured along the centerline of the roadway, and rounded to the nearest hundredth of a (0.01) mile.

834.05 Payment

Accepted quantities will be paid at the contract price per unit of measurement for the Section 834 pay items listed in the Schedule of Items. Payment will be full compensation for the work prescribed in this section.

NOTE: Mobilization is incidental to pay items.

Pay Item Description Pay Unit

834(01) Clean Culverts, 24” diameter and less Each 834(02) Clean Culverts, 24” – 48” diameter Each 834(03) Clean Culverts, greater than 48” diameter Each 834(04) Clean Ditches Mile 834(05) Clean Ditches, Culverts, and Drainage Structures Mile 834(06) Clean Drainage Structures Mile

834.06

Acceptable Quality Levels for Culvert/Ditch/Drainage Structure Cleaning

Description Major Defect Allowable Major Defects

Action Required to Correct Major Defects

Minor Defect Allowable Minor Defects

Action Required to Correct Minor Defects

Drainage Systems

(Ditches and Structures

Designed to Facilitate Roadway Drainage)

Obstructions remaining in drainage systems specified for cleaning

None, except those beyond 2 feet inside culvert inlets & outlets

Remove obstructions, except those beyond 2 feet inside culvert inlets and outlets

Obstructions remaining in drainage systems

Obstructions beyond 2 feet inside culvert inlets & outlets Report to COR

Major damage to culvert from contractor’s operation

None

Repair damage to restore adequate function, or replace culvert in accordance with Forest Service specifications, at the contractor’s expense

Minor marring or surface damages to culvert materials

No limit, if corrective actions are taken.

Otherwise, replace with new materials

Ensure marred areas are treated with an approved cold galvanizing compound

Template Undercutting of the backslope None

Replace missing backslope material with compacted rock material approved by the COR, at the contractor’s expense

Traveled Way

Debris from drainage system cleaning remaining in traveled way

None Remove debris to provide a clear traveled way

Traveled Way

Equipment causing potential damages to asphalt surface

None

Cease operation immediately and resume maintenance when surface is stable

Equipment causing potential damages to non-asphalt surfaces

Minor disturbances to aggregate or native surface materials

None, unless more than 2” deep or will compromise roadway drainage. Otherwise, smooth and compact area of disturbance.

Road use and Maintenance Use of Roads

(a) The Contractor is authorized to use roads that are a part of the construction project and those Forest Service roads designated below for performance of work under this contract.

(b) If the Contractor requests use of a National Forest road or segment not designated for his use, the Forest Service may authorize such use if not in conflict with the current Road Rules document. Authorization to use such additional roads may include maintenance requirements and use limitations.

(c) The roads authorized for use will be subject to the following provisions:

1. The Road Rules in the current Umatilla National Forest Road Rules Document are applicable to all commercial road users.

Umatilla National Forest - Other Permits (usda.gov)

2. State laws governing traffic rules and equipment requirements on State and County highways.

3. Federal regulations contained in 36 CFR 261.12. These regulations prohibit use of vehicles or equipment in excess of State legal highway loads or posted limits without valid State and Forest Service overload permits, damaging a road while using it, and blocking a road open to use by others, except as may be otherwise provided in the contract.

Load Limits --All vehicles and equipment shall not exceed State legal highway loads and widths or posted limits without valid State and Forest Service overload, overwidth permits. Forest Service overload permits for this project may be obtained from the District Ranger.

4. Federal Regulations contained in 36 CFR 261.54 as applied to the area by an order issued under 36 CFR

261.50. These regulations authorized the Forest Service, as a sovereign act, to issue additional restrictions and closures any time conditions warrant. Such closures will be in addition to those shown in the current Road Rules Document and will be posted on the road.

Contractor’s Request for Substitution

A. In making formal request for substitution the Contractor represents he/she:

1. Have investigated proposed product and determined that it is equal to or superior in all respects to that originally specified.

2. Will provide same warranties and bond for substitute as for originally specified product.

3. Will coordinate installation of accepted substitution into the work, and will make such changes as may be required for the work to be complete in all respects.

4. Will waive claims for additional costs caused by substitution, which may subsequently become apparent.

5. Cost data is complete and includes related costs under the contract, but not:

a. Costs under separate contracts.

b. Contracting Officer costs for redesign or revision of contract documents.

B. The Contractor assumes full responsibility that the substitution and/or alternate items or procedures proposed will meet the job requirements.

https://www.fs.usda.gov/main/umatilla/passes-permits/other

C. The Contractor is solely responsible for the cost of redesign and modifications to this and other parts of the work caused by the substitutions or alternates furnished.

Appendix B: Example Forest Service Daily Diary The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

USDA - Forest Service FS-6300-0020 Rev 01/17

CONTRACT DAILY DIARY

(Reference FSH 6309.32)

1. FOREST

2. CONTRACT NO.

3. PROJECT

4. CONTRACTOR 5. CONTRACTOR

REPRESENTATIVE ON SITE

6. GOVERNMENT OFFICIALS ON SITE

7. DATE 8. DAY OF WEEK 9. TIME ARRIVED 10. TIME DEPARTED 11. WEATHER

12. TEMPE

Min.

RATURE °F.

Max.

13. GROUND CONDITION 14. CONTRACT TIME 15. DAYS USED 16. COMPLETION DATE

17. TIME USED (%) 18. WORK COMPLETED (%) 19. WORK ON SCHEDULE 20. CONTRACTOR'S WORK - (X Appropriate Box)

YES NO Acceptable Unacceptable - Explain in narrative

21. CHANGE ORDERS/AMENDMENTS ISSUED 22. WORK ORDERS ISSUED (Include SUSPEND/RESUME)

23. MATERIALS FURNISHED TO JOB SITE (Furnished By: G-Govt.; C-Cont.; S-Subcont.) 24. LIST EQUIPMENT ON SITE (Furnished by G-Govt.; C-Cont.; S-Subcont.)

Type Contract Item Number and Location of Use Hours Used

25. LIST CONTRACT PAYMENTS, REPORTS, CORRESPONDENCE, ETC. 26. WORKERS ON SITE Number

Item Prep Submit Classification PRIME SUB

27. GOVERNMENT PROVIDED SERVICES ADEQUATELY AND TIMELY

YES NO - Explain in narr ativ e

28. NARRATIVE REPORT

29. SIGNATURE 30. TITLE 31. ADDTL SPACE NEEDED

(continued on 6300-21)

Appendix C: Customer Feedback Record The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

CUSTOMER FEEDBACK RECORD

DATE AND TIME OF COMPLAINT CONTRACT NUMBER/ OR PROJECT:

SOURCE OF COMPLAINT

ORGANIZATION

INDIVIDUAL

NATURE OF COMPLAINT

PWS REFERENCE

VALIDATION

DATE AND TIME CONTRACTOR INFORMED OF COMPLAINT NAME OF CONTRACTOR REPRESENTATIVE INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR (Responsible officer):

RECEIVED AND VALIDATED BY

Determination: Complaint Valid Complaint Invalid