Attachment 8 Non Conformance Report Worksheet.docx
DOCX document 59 KB Posted
- Attached to
- ARMY DIRECT CARE MEDICAL SERVICES (ADCMS) IV
- Solicitation number
- W9114F22R0002
- Issued by
-
Department of the Army Medical Command
About this file
This document is a non-conformance report worksheet template to be used for tracking contractor performance issues on an Army contract for direct care medical services at Landstuhl Regional Medical Center and other overseas military treatment facilities. The template includes fields for identifying the contracting agency and contract reference, describing the nonconformance issue and location, capturing the contractor's corrective action plan and responses, and tracking validation and closure of the nonconformance. Major and critical issues require the contractor to submit a corrective action plan by the specified due date, which is then reviewed and either accepted or rejected by the government. The worksheet allows for attaching evidence to support nonconformance reporting and tracking repeat issues and overall rating adjustments.
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Text version
Command
Organization Office
DODAAC of Office who will issue Nonconformance to Contractor Awarding Contracting Agency DoD Non DoD Task/Delivery Order (Refer to FAR Subpart 4.16 )
52.212-4 Clause Included in Contract? Yes No
Contractor required to have Quality Management and/or Quality Control Plan? Yes No Commercial Contract Yes No Program Name
| Contact Information for individual who identified nonconformance | |||
| First Name | Last Name | Position E-mail address | |
| Commercial Phone number | DSN Phone number |
| Contact Information for individual reviewing nonconformance | |||
| First Name | Last Name | Position E-mail address | |
| Commercial Phone number | DSN Phone number |
| Contact Information for individual to Issue nonconformance | |||
| First Name | Last Name | Position E-mail address | |
| Commercial Phone number | DSN Phone number |
Calendar Year (CY) Nonconformance Observed Overall Nonconformance Rating Name of Contractor
Contractor CAGE Code
First Name Last Name )Point of Contact (POC) at Contractor receiving NCR
Contractor POC Title (position)
Contractor POC E-Mail Address
Contractor Address (Street or PO)
Contractor City
Contractor State Nonconformance Report Worksheet
Clear
Form NCR Tracking number
1_Oct_2018 Contractor Zip Code
)Contractor Country
1 NC Tracking Number 1
Date Nonconformance Observed Child Nonconformance Rating Location where nonconformance was observed
Contract Reference Requirement Nonconformance Description
| Additional Remarks | N/A |
| Is there intentions to have pictures, examples, or other supporting evidence attached? Yes | No Steps used by Government to validate Contractor CAP was implemented |
Date Child Nonconformance Closed
| Add Nonconformance |
| Remove Above Nonconformance |
Reviewer Concurs Yes No Date Reviewed (to be completed by reviewer) Reviewer Comments
Date Issued to Contractor
Response Due Date (to be completed by issurer) Complete section below for Major (Level 2) and Critical (Level 3)
| Contractor Corrective Action Plan (CAP) received by Due Date? |
| Yes |
| No |
| Date CAP Received |
Has Contractor requested an extension ?
Contractor Corrective Action Plan (CAP)
| Yes |
| No |
| New Response Due Date |
Received CAP acceptable to Government ?
Yes No Date CAP Accepted Date CAP Rejected Date Contractor expecting to have CAP Implemented awaiting validation by Government Enter Revised or
New
CAP
Remove Current Instance )Rationale for CAP Rejection
Expected Validation Date
Individual who performed validation Validation Date Was Corrective Action Successful? Yes No Date Nonconformance closed by Government Does this NCR need to be cancelled? (only when applicable) Yes No Does this NCR need to have overall level adjusted? (only when applicable) Yes No image5.png image1.png image2.png image3.jpeg image4.jpeg
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