Attachment 4 - Sample Quality Assurance Monitoring Form.pdf

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Kitchen Attendant Services
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W50S9222Q9012
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Pennsylvania Air National Guard (PANG)

SAMPLE QUALITY ASSURANCE MONITORING FORM

Dated: 24 June 2022

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint

LEVEL OF SURVEILLANCE (Check):

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): Meets Standards

Does Not Meet Standards Narrative of Performance During Survey Period:

PREPARED BY: DATE:

SURVEY PERIOD:
SURVEILLANCE METHOD (Check):
LEVEL OF SURVEILLANCE (Check):
PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: %
Observed Service Provider Performance Measurement Rate: % Service Provider’s Performance (Check): Meets Standards

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