Attachment 1 SOW Rev1_Janitorial Svcs_Aberdeen PMC_3Feb26.pdf

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NRCS-ID Aberdeen Plant Materials Center (PMC) Janitorial Services
Solicitation number
12FPC326Q0005
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This is a Statement of Work (SOW) for janitorial and custodial services at the Natural Resources Conservation Service (NRCS) Aberdeen Plant Materials Center in Aberdeen, Idaho. The contract requires one 12-month base period and four optional 12-month renewal periods with services performed one day per week for approximately 3,000 square feet of building space. The contractor must furnish all labor, supervision, equipment, transportation, and supplies except those identified as government-provided, which include utilities, trash collection, paper towels, toilet paper, wastebasket liners, hand soap, and hand sanitizer. All cleaning products must be environmentally preferable and certified by Green Seal, Greenguard, or similar organizations, with preference for biobased products from the USDA Designated Biobased Products List. The contractor must submit Material Safety Data Sheets (MSDS) for all cleaning products and maintain a detailed log of materials in use and storage.

Weekly services include damp mopping and disinfecting hard floors, cleaning entrance doors and glass, vacuuming carpets, emptying trash, and thoroughly cleaning and disinfecting restrooms. Biannual services include window cleaning inside and outside, floor mat shampooing, and deep carpet cleaning twice yearly. The contractor must submit a Cleaning Operations Plan within 30 days of award defining responsibilities, cleaning products, timelines, and hazardous material storage procedures in compliance with NFPA Code and RCRA regulations. Work must be performed outside normal office hours (6:00 a.m. to 6:00 p.m.) with scheduling coordinated with the Contracting Officer Technical Representative (COTR). All contractor personnel require federal identification cards issued following background investigations and National Agency Checks (NAC/NACI). Quality control is assessed through periodic visual inspections using a Quality Assurance Surveillance Plan, with deficient work subject to re-cleaning at no additional cost. Federal holidays require advance scheduling of makeup services, and facility defects must be reported to the COTR immediately for safety hazards or within one business day for routine maintenance issues.

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Statement of Work (SOW) Janitorial Services, Aberdeen Plant Materials Center (PMC)

NRCS Idaho State Office

A. SCOPE OF THE WORK

The NRCS Aberdeen Plant Materials Center (PMC) has a requirement for high quality janitorial services at the location stated herein, in accordance with these specifications and other terms and conditions set forth. The work covered under these specifications consists of performing all operations in connection with janitorial/custodial services in the buildings.

The Contractor shall furnish all labor, supervision, equipment, transportation, quality control, and supplies necessary (except those identified as Government provided) to satisfactorily perform the services specified. It is intended that the services will include, whether specifically listed, all functions normally considered a part of commercial janitorial/custodial work.

Place of Performance: The work site is located at the Natural Resources Conservation Service, Aberdeen PMC, 1691A South 2700 West, Aberdeen, Idaho (approximately 110 miles northeast of Twin Falls, ID and 40 miles west southwest of Pocatello, ID). The building to be covered by these services is approximately 3,000 sq. ft. The building shall be cleaned one day a week.

All cleaning supplies and materials shall meet environmentally preferable cleaning products as certified by Green Seal, Greenguard or similar organizations. A Material Safety Data Sheet (MSDS) shall be obtained and given to the Contracting Officer Technical Representative (COTR) for all cleaning products stored onsite. Also, all cleaning products used shall be equal to the most suitable grade of the respective article as is used in standard acceptable cleaning operations.

Period of Performance: The period of performance shall be for one (1) 12-month base period and four

(4) 12-month option periods.

Government-Furnished Facilities/Supplies:

The following facilities are provided for the Contractor's use during the term of the contract:

1. Availability of Utilities. The Government will furnish the following utility services at existing outlets, for use in those facilities provided by the Government and as may be required for the work to be performed under contract: electricity, fresh water, sewage service, and refuse collection (from existing collection points). Information concerning the location of existing outlets may be obtained from the COTR. Utilities specified above will be furnished at no cost to the Contractor. The Contractor shall provide and maintain at his/her expense, the necessary services from existing Government outlets to the site of the work.

2. Trash dumpsters and trash collection provided by the Government.

3. Government Furnished Supplies to include:

(a) Paper Towels

(b) Toilet Paper

(c) Wastebasket Liners

(d) Hand soap and/or liquid soap

(e) Hand Sanitizer/Disinfectant

4. Lights shall be used only in areas where and when work is being performed and turned off after work is completed.

5. Mechanical equipment controls for heating, ventilation and air conditioning systems shall not be adjusted by Contractor employees.

6. Turning off the water faucets or valves after using the required usage has been accomplished.

7. Contractor’s employees shall not use telephones at the work site for personal reasons or make any toll or long-distance calls. The Contactors employees shall not use any computers at the work site for any purpose.

8. Any facility defects noticed, such as dripping faucets, leaking or clogged toilets, broken locks, etc.

shall be reported to the COTR no later than the next workday. Emergencies such as safety hazards, security faults (an open window, either interior or exterior that cannot be secured) or critical damage to facilities shall be reported immediately to the COTR.

9. Access to the main entrance of the building is by use of a key. Side access doors require pin numbers to be entered into keypad for entry. Contractor personnel will be issued a key for entrance to the front door and PIN number provided for side service entrances. (See attachment 1, Key Control Plan requirements). Upon termination of a contract employee or at the end of the contract, the Contractor will ensure all keys are returned to the COTR within 24 hours or the next business day if it falls on the weekend or Federal holiday.

Contractor-Furnished Supplies:

General: The Contractor shall furnish all labor, cleaning supplies, materials, equipment and supervision required to perform work under this contract, other than the items listed above in para A3. All other supplies and materials shall be of a type and quality that conform to applicable Federal specifications and standards. Supplies, materials and cleaning chemicals that are used in the performance of this contract are subject to the approval of the COTR.

Equipment: All electrical equipment furnished by the Contractor shall meet all safety requirements of this SOW and shall be UL approved. This equipment shall operate using existing building circuits and prevent the operation of equipment that may exceed the power capacity. All equipment shall be maintained by the Contractor to provide an efficient and continuing operation. The different types of equipment shall be the responsibility of the Contractor; however, the quantity shall be sufficient to maintain the approved Schedule of Work with consideration for equipment breakdowns and routine maintenance. Inoperable equipment is not cause for cleaning work not to be performed.

The Contractor shall provide their employees the proper safety equipment required to complete the applicable tasks identified in this SOW.

Cleaning Product Submittal: Prior to contract startup, the Contractor shall submit a list of proposed cleaning products, along with the Material Safety Data Sheet (MSDS), to be used in accordance with the contract specifications, to the COTR. Once initial cleaning products have been approved for use, the Contractor shall submit for approval any new or substitute products along with the related MSDS that the Contractor proposes to use. The Contractor shall keep a log with attached MSDS, which details all materials currently in use, all materials that remain but are no longer used, and a list of materials stored in vehicles and/or storage sites.

The Contractor shall prioritize using products and material made from biobased materials (e.g., biobased cleaners, biobased degreasers, biobased laundry detergent) to the maximum extent possible. For the biobased content products evaluation, products proposed for use under this contract must conform to the Department of Agriculture (USDA) Designated Biobased Products List (DBPL). Product list is available at www.biopreferred.gov/BioPreferred/faces/Welcome.xhtml. If requested in the contract, Contractors shall provide data for their biobased solvents and cleaners to document the level of biobased content.

Products to Be Provided by the Contractor:

The following is a list of products USDA requires for custodial purposes. Each product submitted must be identified with one of these categories. It is desirable that vendors be able to supply the greatest number of biobased products listed meeting health and environmental specifications. Labeling should be printed on all containers.

All Purpose Cleaner Degreaser/cleaner

Heavy duty cleaner Deodorizer

Wood floor cleaner Glass cleaner

Floor finish Cream cleaner

Floor finish restorer Extraction fluid

Floor sealer Furniture polish

Floor stripper Toilet bowl cleaner

Neutral cleaner (liquid) Solvent spotter

Spot and stain remover Lime and scale remover (tub and tile cleaner)

Air freshener Stainless steel polish

Bathroom cleaner Chrome polish/cleaner

Brass polish/cleaner

Required Submittals and Reports:

Within thirty (30) days of contract award, the Contractor shall submit a Cleaning Operations Plan ("Plan") (see below for plan specifications). This submittal shall be reviewed by the COTR and approved in writing. The Contractor shall not commence work until this submittal is reviewed and approved. The Contractor is responsible for making such revisions to the Plan as are deemed necessary by the COTR.

If the Plan requires any revisions or corrections, the Contractor shall resubmit the Plan within ten (10) days. No work will be allowed, and no progress payments will be processed until the Plan is approved.

Cleaning Operations Plan Specifications Key Deliverables

Item No.

Deliverable Objective Due

1 Cleaning Material List

Provide the Government with a list of ‘green’ supplies for use

Prior to the start of the performance of contract

2 Cleaning Operations Plan

Defining the responsibilities, timeline, risks, cleaning products, cleaning timeline and contract objectives.

No later than thirty (30) business days after contract award

3 Revisions of Plan-If needed after COTR review

Correct and make any revisions as requested by the COTR

Resubmit within (10) days

1. Cleaning Operations and Stewardship Plan. The Plan must be reviewed and updated annually, and as required by the COTR. The Plan must contain and define the following elements:

(a) The Contractor's written policy stating its priority to the use of biobased products, employee health and safety, and sound environmental management practices.

(b) Proposed biobased cleaning products that must be selected in accordance with the criteria included in the solicitation. At a minimum, the Plan must identify products by brand name for each of the above product types.

NOTE: Contractors may propose more than one (1) product within a designated item and/or propose a product or products addressing more than one designated item

(c) The product attributes for the proposed product brands in each of the above categories must be summarized. Once this list of products has been approved by the COTR and/or the CO, the Contractor is responsible for using only those approved cleaning chemical products in the building.

If for some reason the product is found later to be ineffective, or the Contractor would otherwise like to propose an alternative product, either the Contractor or the COTR may propose for consideration an "equal" product. The COTR is the final decision-maker for such substitutions and must approve each in writing.

(d) Product Use and Cleaning Guides which define standard operating procedures for instructing staff in the following areas: the proper use, storage, and disposal of cleaning products; proper cleaning procedures; proper operation of equipment; and other procedures/instructions to accomplish work under this contract; and

(e) The Contractor shall define proper procedures for the storage of hazardous materials in conformance with good housekeeping practices, the National Fire Prevention Association (NFPA) Code, and applicable Federal and municipal regulations. The Plan also must define proper procedures for the identification and disposal of hazardous wastes in accordance with Federal

RCRA regulations and the District of Columbia Municipal Regulations (DCMR), Title 20, Subpart E prior to use with personnel. The Government building has two cabinets under the sinks in the lab available for chemical storage.

2. Affirmative Procurement Program. The Contractor shall implement the requirements of the agency's comprehensive Affirmative Procurement Program for the purchasing of biobased products to the maximum extent possible. www.epa.gov/sites/default/files/2016-02/documents/app.pdf. The Contractor shall detail how it intends to keep abreast of the development and increasing availability of biobased products and how any new or improved products will be incorporated on an ongoing basis into contract performance.

3. Material Safety Data Sheet. The Contractor shall obtain and have on file a Material Safety Data Sheet (MSDS) for all hazardous materials used and stored by the Contractor.

Management:

The Contractor shall provide an adequate staff of personnel with the necessary management expertise to ensure the performance of the work in accordance with sound and efficient management practices.

The Contractor shall maintain an adequate work force to complete work in accordance with the time and quality standards specified herein.

1. Work Control: The Contractor shall implement all necessary work control procedures to ensure timely accomplishment of work requirements, as well as to permit tracking of work in progress.

The Contractor shall plan and schedule work to assure material, labor, and equipment are available to complete work requirements within the specified time limits and in conformance with the quality standards established herein.

2. Work Schedule. The Janitorial services shall be performed outside of normal office hours (Office hours 6am-6pm). Contractor shall discuss scheduled times allowed for performance of their duties with the COTR. No deviation from selected time and day will be allowed except when given advance permission by the COTR.

3. Protection of Government Property. The Contractor shall protect Government property to the utmost extent practical. Any accidental splashes of hazardous or other liquid material shall be removed immediately and the area returned to its original state. If any damages are determined to be due to the negligence of the Contractor, the Contractor shall be responsible for applicable repairs.

B. CONTRACTOR PERSONNEL SECURITY AND BACKGROUND CHECK

Per U.S. Department of Agriculture Departmental Regulation 4620-002 Common Identification Standard for U.S. Department of Agriculture Employees and Contractors, performance of this contract requires the Contractor and/or their personnel to have a Federal Government-issued personal identification card before being allowed unsupervised access to the NRCS facility. The COTR will be the contact and will make the arrangements for personal identity verification and card issuance. Within 10 days after contract award, the Contractor shall coordinate with the COTR to schedule an appointment to initiate the screening and background investigations for all contract personnel. The Contractor shall provide a list of all employees (to include name, email address, physical and mailing address, phone number and date of birth) that will be performing services for this contract. The Contractor shall ensure all are available at the requested location specified by the COTR to initiate screening and background investigations.

The Government shall assume costs associated with completing the initial security and background checks for the Contractor and/or their employees. Beyond the original crew, the Contractor shall be responsible for all costs to complete the security and background checks for additional personnel.

The COTR may contact Contractor personnel being screened or investigated in person, by telephone or in writing, and the Contractor agrees to make them available for such contact.

Alternatively, if an individual has already been credentialed by another agency through OPM, and that credential has not yet expired further, investigation may not be necessary. The Contractor must provide the COTR with documentation that supports the individuals' status. The Contractor shall keep the COTR apprised of changes in personnel to ensure that performance is not delayed by compliance with the credentialing process.

Any identification cards and/or keys that have been lost, damaged, or stolen must be reported to the COTR and Issuing Office within 24 hours. Replacement will be at the Contractor's expense. If reissuance of expired credentials is needed, it will be coordinated through the COTR.

Before starting work under this contract, a National Agency Check (NAC) will be conducted to verify the identity of the individual applying for clearance. Upon successful completion of the NAC process, an identification card will be issued and access granted.

Simultaneously, an NAC with Inquiries (NACI) will be initiated to determine the individuals' suitability for the position. If the NACI adjudication is favorable, nothing more needs to be done. If the adjudication is unfavorable, the credentials will be revoked. In the event of a disagreement between the Contractor and the Government concerning the suitability of an individual to perform work under this contract, USDA shall have the right of final determination.

This requirement must be incorporated into any subcontracts that require subcontractor personnel to have regular and routine unsupervised access to a Federally controlled facility for more than 180 calendar days or any unsupervised access to a Federally controlled Level 3 or 4 information systems.

Contractor Damages: The Contractor shall notify the COTR within 24 hours of any damage discovered while in the performance of their work. The COTR will decide as to the extent of the damage and if the damages were caused by the Contractor employee. This includes noticeable damage found on the exterior of the building as well. The Contractor shall make all necessary repairs of the damages, at the Contractor’s expense, within 30 calendar days. Once repairs have been completed, the Contractor will notify the COTR for final inspection and acceptance.

C. SAFETY REQUIREMENTS

All Contractor personnel shall comply with all applicable Federal, State and local laws while engaged in the performance of this contract to include safety policies and regulations established by the NRCS. (All hard copy publications are available via the referenced websites below).

Supplements or amendments to listed publications may be issued during the life of the contract.

1. Occupational Safety and Health. The Contractor shall comply with all provisions of the William- Steiger Occupational Safety and Health Act of 1970, all applicable safety and health regulations that have been promulgated by the Secretary of Labor under the Williams-Steiger Occupational Safety and Health Act of 1970, to include 29 Code of Federal Regulation (CFR) Part 1910 (Occupational Safety and Health Standards), and all applicable safety and health codes and standards of the state and local jurisdictions where the work is to be performed. Periodic inspections will be made by the Government to ensure safe and healthy working conditions. Provisions of the William-Steiger Occupational Safety and Health Act of 1970 and the Occupational Safety and Health Standards can be found at the following links:

(a) William-Steiger Occupational Safety and Health Act of 1970 http://www.osha.gov/pls/oshaweb/owasrch.search form?p doc type=OSHACT

(b) 29 (CFR) Part 1910 Occupational Safety & Health Standards http://www.osha.gov/pls/oshaweb/owastand.display standard group?p toe level= I&p part numbei=l 910

2. Safety, Health and Environmental Requirements. The Contractor shall ensure that personnel comply with all NRCS safety, health, fire protection, and security policies, guidelines, and directives. The Contractor shall ensure safety in the assigned work areas and shall identify safety hazards to the

COTR.

3. Energy Conservation. The Contractor shall participate in Government utility conservation and resource recycling programs. The Contractor shall instruct all personnel in energy and resource conservation practices and shall require them to operate utilities under conditions that preclude wasteful use of energy. Current recycling programs include aluminum cans, paper, and printer ink cartridges. Federal guidelines concerning recycling can be found at http://www.ofee.gov

Federal Observed Holidays: The Contractor shall submit to the COTR an alternate schedule that will be affected by federally observed holidays not later than ten (10) workdays prior to the holiday. The schedule shall include dates for make-up of all buildings affected by the holiday.

January 1st (New Year’s Day) 1st Monday of September (Labor Day) 3rd Monday of January (MLK Jr.’s Birthday) 2nd Monday of October (Columbus Day) 3rd Monday of February (President’s Day) November 11th (Veteran’s Day) Last Monday of May (Memorial Day) 4th Thursday of November (Thanksgiving Day) 19th Day of June (Juneteenth National Independence Day) December 25th (Christmas Day) July 4th (Independence Day)

If an unforeseen building closure occurs on a regularly scheduled day of work, the Contractor will have the following options:

Schedule the work so it is performed the following day unless the following day falls on a weekend.

Schedule the work on any day that is mutually satisfactory.

The Contractor shall perform and complete Scheduled Cleaning Services during specified hours mutually agreed to by the COTR and the Contractor.

The Contractor personnel shall be allowed access to the building to perform scheduled custodial services or work subject to the limitations in this SOW.

The Contractors personnel shall not be permitted access to the building on non-cleaning days or during hours when no work is scheduled, except when prior arrangements have been made between the Contractor and the COTR.

D. MINIMUM SERVICES REQUIRED

Each specifically stated service shall be performed as and when indicated. The work shall be performed other than office hours, which are from 6:00 a.m. to 6:00 p.m., and except for Federal Holidays. If there are some required services which cannot be conveniently performed other than during office hours, the Contractor shall coordinate the time changes with and obtain approval from the COTR prior to working the changed hours and/or days.

1. Weekly Services:

(a) Front office, Entrances, Hallways and Lobby:

(1) Damp mop and clean all hard and resilient floors with hot water and disinfectant cleaner.

(2) Clean both sides of glass entrance doors and metal surrounding doors.

(3) Clean soiled areas on floor mats.

(4) Vacuum carpet and floor mats.

(5) Empty trash receptacles and move trash to designated disposal area.

RESULT: Mopped floors shall have a uniform appearance with no streaks, swirl marks, detergent residue, soap scum or any evidence of soil, stains, film debris or standing water. There shall be no splash marks or mop streaks on furniture, walls, baseboards, trash receptacles, or mop strands remaining in the area. Mats shall be free of all visible lint, dirt, dust, litter, soil, and other foreign matter. Glass shall be free of lint, streaks, smudges, smears, water spots, dust, and any other foreign matters upon completion of service.

(b). Restrooms:

(1) Thoroughly sweep and damp mop tile floors, thoroughly clean soiled spots with disinfectant cleaner. Do not use waxes, polishes or abrasive cleaners on tile flooring.

(2) Wash toilets, seats, urinals inside and out, and behind walls with a disinfectant detergent.

Seats shall be left in the raised position.

(3) Clean and disinfect sinks, mirrors, shelves, soap dispensers, tissue holders, towel dispenser, pipes and any other chrome or satin finish material. Do not use abrasive cleaners.

(4) Replenish Government provided supplies such as paper towels, toilet tissue and soap.

(5) Empty trash receptacles and move trash to designated disposal area.

RESULT: Fully supplied, clean, disinfected Restrooms/Toilet Areas. All surfaces shall be free of odor, stains, mold, mildew, dirt, dust deposits, streaks, and smudges. Partitions, stalls, stall doors, entry doors, (including handles, kick plates, ventilation grates, metal guards, etc.), and wall areas adjacent to wall-mounted lavatories, urinals, and toilets shall be disinfected. Toilets, and urinals shall be free of water spots, scale buildup, soap scum and other deposits. Walls and grout shall be free of all film, spots and detergent buildup.

(c) Office rooms, work area, lab and conference room:

(1) Damp mop and clean all hard and resilient floors with not water and a disinfectant cleaner.

(2) Clean any anti-static mats and vacuum all exposed carpeted areas including under furniture, i.e. desks, tables etc.

(3) Spot dust horizontal surfaces, i.e., tables, desks, computers.

(4) Clean soiled areas on carpets.

(5) Empty waste baskets and remove trash to designated disposal area.

RESULT: Mopped floors shall have a uniform appearance with no streaks, swirl marks, detergent residue, soap scum or any evidence of soil, stains, film debris or standing water. There shall be no splash marks or mop streaks on furniture, walls, baseboards, trash receptacles, or mop strands remaining in the area. Mats shall be free of all visible lint, dirt, dust, litter, soil, and other foreign matter.

(d) Drinking fountains: – clean, disinfect and polish all drinking fountains

RESULT: Drinking fountains shall be free of streaks, stains, spots, smudges, scale, hard water deposits, dust, and other obvious soil/dirt.

2. Biannual services in office and conference room:

(1) All windows shall be cleaned inside and outside resulting in a streak free appearance.

(2) The floor mats at each entrance shall be shampooed

(3) All carpeted areas shall be shampooed and deep cleaned two (2) times per year

RESULT: Glass, adjacent trim and window screens shall be free of lint, streaks, smudges, smears, water spots, dust, and any other foreign matters upon completion of service. After shampooing, the carpeted area will be uniform in appearance and free of stains, soil, and discoloration or visible spots. All cleaning solutions shall be removed from baseboards, furniture, trash receptacles, chairs, and other similar items.

3. Miscellaneous Duties: In addition to the work specified above, the Contractor shall turn off all lights in the rooms that are not occupied.

4. Report the following to the COTR:

(1) Report fires, hazardous conditions and items in need of repair.

(2) Report any signs of insects I rodents.

(3) Report any open or unlocked entrance doors.

(4) Report any harassment that occurred while on the site.

(5) Report any packages left at the front door without disturbing it.

(6) Report and close any window left open

5. Lost and Found: All articles found by Contractor personnel to whom a reasonably prudent person would assign monetary, personal, or other value (including possible contraband items) shall be immediately reported to the COTR. The Contractor shall obtain receipts for articles given to the COTR.

E. QUALITY CONTROL, INSPECTION AND ACCEPTANCE OF WORK

1. The Contractor shall be responsible for the quality of services provided under the contract, including those provided by subcontractors. The Contractor shall achieve an acceptable performance rating in accomplishing the tasks and services listed herein. The performance rating will be based on the results of an inspection process that the Government will administer using the Quality Assurance Surveillance Plan (QASP). The areas inspected will follow the minimum service required tasks. An acceptable performance rating is achieved when completion of services follows results and meets those standards. The Government will inspect services under this contract to assess the Contractor's overall performance (Monitoring form below). The results of the inspections will determine overall satisfaction with various services provided, focusing primarily on the timeliness and quality of these services. If any services performed do not meet standards, the Contractor will be allowed to ‘re-clean’ the area to a satisfactory appearance.

2. Scheduled services will be periodically sampled as needed by the COTR to ensure satisfactory completion. If one or more of the services are not completed in compliance with the contract requirements (non-performed or unsatisfactorily performed) or unacceptable quality, the Government will have the choice of either requiring the Contractor to re-perform the work or let it go until the next scheduled occurrence, depending on the importance level of the requirement.

3. At any time, the COTR may request the Contractor to participate in conference calls or meetings to review contract performance. Discussions shall include review of contract performance, issues, suggestions for changes in the business process, etc. In the event performance problems exist, the parties will discuss achieving a mutual resolution.

4. When the Contractor has been informed of defective services, the Contractor must rework the task or service possible. The COTR will evaluate the defective service and the impact thereof. Based upon criticality, the COTR may decide to strictly document the defects and report them by email to the Contractor and not allow further expenditure of resources for rework.

Performance Requirement Measures

Performance Objectives

Performance Indicator

Performance standard

Method of Surveillance

Acceptable Quality Level

Weekly Services

Quality Services delivered as requested

Delivery matches requested results

Visual Inspection by Plant Materials

Center Staff

Meets standards on Quality Assurance

Monitoring form (below)

Biannual Services

Quality Services delivered as requested

Delivery matches requested results

Visual Inspection by Plant Materials

Center Staff

Meets standards on Quality Assurance

Monitoring form (below)

Quality Assurance Monitoring Form

Contract Number:

Service or Standard:

Survey Period:

SURVEILLANCE METHOD (Check the applicable item):

☐ Random Sampling ☐ 100% Inspection ☐ Periodic Inspection ☐ Customer Complaint

LEVEL OF SURVEILLANCE (Check the applicable item):

☐ Monthly ☐ Quarterly ☐ As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check the applicable item):

☐ Meets Standards

☐ Does Not Meet Standards

Narrative of Performance During Survey Period:

Name of Preparer Date:

Title:

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