Attachment 8 Non Conformance Report Worksheet.docx
DOCX document 59 KB Posted
- Solicitation number
- W9114F23R0002
- Issued by
-
Department of the Army Medical Command
About this file
This document is a non-conformance report worksheet template to be used for reporting issues with contractor performance on a federal contract for behavioral health and traumatic brain injury services in Europe awarded by the Department of the Army Medical Command. The template includes sections for tracking numbers, dates, descriptions of non-conformances observed, contractor corrective action plans, validation of corrective actions taken, and closure of non-conformance reports. It appears to be designed for documenting and resolving any failures by the contractor to meet the quality, schedule or other contractual requirements for providing behavioral health and traumatic brain injury services to Landstuhl Regional Medical Center and other overseas military medical facilities as outlined in solicitation number W9114F23R0002.
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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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