Attachment 5 - Initial Headstone-Marker Raise and Realign Verification Survey.pdf
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- 36C78626B0014
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This document is a template form for conducting an initial headstone and marker raise and realign verification survey in a cemetery setting.
The form requires the Contracting Officer's Representative (COR), Cemetery Director, Cemetery Foreman, or Work Leader to conduct a comprehensive survey of all headstones and markers included in the contract scope of work before any work begins. The survey must utilize the Burial Register Report and Gravesite Layout Maps as reference documents. The form captures essential information including station number, date, cemetery name, cemetery director identification, and the COR's name. A section documents any discrepancies or issues identified during the initial survey, with space to note whether discrepancies were resolved and the resolution date. The responsible official must certify completion of the survey and sign and date the form. Additionally, the form establishes a requirement that a Daily Headstone/Marker Raise and Realign Verification Survey be completed by the same officials at the end of each workday, covering all completed work and using the same reference documents as the initial survey. This form serves as a quality assurance and documentation mechanism for cemetery headstone and marker maintenance work.
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ATTACHMENT 5
INITIAL HEADSTONE/MARKER RAISE & REALIGN VERIFICATION
SURVEY
Station Number: __________ Date: __________________________
Cemetery: _______________ Cemetery Director: _______________
Contracting Officers Representative: ______________________________________
Instructions: The Contracting Officer’s Representative (COR) /Cemetery Director/Cemetery Foreman/ Work Leader/designee MUST conduct an initial survey of ALL headstones/markers included in the scope of work (SOW) before any work is performed. The COR/Cemetery Director/Cemetery Foreman/Cemetery Work Leader/designee will use the Burial Register Report and the Gravesite Layout Map(s) for the initial survey.
Discrepancy/Issue Identified: Y/N_______ Date: ____________________
All discrepancies/issues resolved Y/N ________ Date: ____________________
I certify that the Initial Headstone/Marker verification survey was completed by the COR/Cemetery Director/Foreman or Work Leader/designee. The Burial Register Report and the Gravesite Layout Map for the Cemetery and sections listed in the SOW were used to complete the survey.
COR/Director/Foreman/Work Leader/designee Signature: ______________________
Date: _________________
Prior to the completion of the workday, a Daily Headstone/Marker R&R Verification Survey MUST be completed by the COR/Cemetery Director/Cemetery Foreman/Work Leader/designee utilizing the same Burial Register Report and Gravesite Layout Map as used in the initial survey for ALL completed work.
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