Attachment 5 - Initial Headstone-Marker Raise and Realign Verification Survey.pdf
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- 36C78626B0015
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This is a verification survey template for headstone and marker raise and realign work in cemetery settings. The form serves as a quality assurance document that must be completed by the Contracting Officer's Representative (COR), Cemetery Director, Cemetery Foreman, Work Leader, or designee before and after headstone/marker work is performed.
The initial survey must be conducted on all headstones and markers included in the scope of work prior to any work commencing. The survey utilizes the Burial Register Report and Gravesite Layout Map(s) to document baseline conditions and identify any discrepancies or issues. The form requires documentation of whether discrepancies were identified and the date, along with notation of when all issues are resolved. The authorizing official must certify completion of the initial survey by signature and date. Additionally, a Daily Headstone/Marker Raise and Realign Verification Survey must be completed at the end of each workday for all completed work using the same reference documents from the initial survey. The template includes fields for Station Number, Cemetery name, Cemetery Director identification, and the COR's name.
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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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