Attachment I Quality Assurance Surveillance Plan_Draft_R4_01182024.pdf

US Department of Agriculture (USDA)

Quality Assurance Surveillance Plan

Contents Project Name Solicitation / Contract Number Section 1: Introduction

1.1 Purpose

1.2 QASP Relation to the Contract

1.2.1 QASP Revisions

1.2.2 Surveillance of Performance Progression

1.3 QASP Relation to the Quality Control Plan (QCP)

Section 2: Performance Description

2.1 Performance Standards and Acceptable Quality Levels (AQLs)

2.1.1 Allowable Deviation

2.1.2 Substantially Complete

2.2 Non-Performance

2.2.1 Documentation

2.2.2 Remedial Actions

Section 3: Contractor and Government Responsibilities

3.1 Contractor Responsibility

3.2 Government Responsibility

3.2.1 Contracting Officer (CO)

3.2.2 Contracting Officer Representative (COR)

3.2.3 Customers

Section 4: Surveillance Methods to Perform Quality Assurance

4.1 Surveillance Methods

4.2 Analysis and Results

Appendix A: Example Performance Requirement Summaries Appendix B: Example Discrepancy Report Appendix C: Customer Feedback Record Appendix D: Example Guide / Inspection List Appendix E: Example Quality Assurance Monitoring Appendix F: Example Customer Complaint Investigation Appendix G: Example Surveillance Activity Checklist

Project Name R4 Prescribed Fire Training

Solicitation / Contract Number Insert Solicitation / Contract Number

Section 1: Introduction This Quality Assurance Surveillance Plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled R4 Prescribed Fire Training. The Intermountain Region of the USFS (R4) requires a contractor(s) to assist the Fuels Program in all aspects of prescribed fire trainings. Some tasks include: plan and instruct training, provide hands on field experience, provide facility and training site logistical support, and work with host sites on presentation/training needs, to name a few. The intent of the mentoring and other educational presentations is to improve awareness and provide operational education to fire professionals, agency administrators, and resource specialists who are responsible for planning and implementing fuels treatments on their unit(s). This plan sets forth the procedures and guidelines that the USDA, R4 Fire and Fuels management, will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

The purpose of the QASP is to describe the systematic methods used to measure performance and to identify the reports required and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards identified in the PWS. This QASP is designed to define roles and responsibilities, identify the performance objectives, define the methodologies used to monitor and evaluate the contractor’s performance, describe quality assurance reporting, and describe the analysis of quality assurance monitoring results.

1.2 QASP Relation to the Contract

1.2.1 QASP Revisions

The Contracting Officer Representative (COR) may make revisions or changes to the QASP procedures and surveillance methods or increase or decrease the degree of surveillance methods at any time during the contract performance period. Changes to the Metric must be incorporated into the PWS, Performance Requirement Summary (PRS) and QASP by a bilateral modification to contract that is issued by the Contracting Officer (CO). A copy of the QASP is provided to the contractor to enable the contractor to enhance its Quality Control (QC) program to perform in accordance with its Quality Control Plan (QCP).

1.2.2 Surveillance of Performance Progression

As the performance period progresses, the levels of surveillance may be altered for service areas where performance is either consistently excellent or unsatisfactory. If consistently good performance, then the amount of surveillance may be reduced. If observations reveal consistent deficiencies, increased surveillance may be implemented.

1.3 QASP Relation to the Quality Control Plan (QCP)

The QCP is a required element of contract and the Contractor shall adhere to its established quality control processes and procedures in managing and performing work as described in the contract. While the QCP represents the way in which the Contractor will ensure its quality and timeliness of services, as defined in the PWS, the QASP represents the way in which the Government personnel specified in Section 3: Contractor and Government Responsibilities, Paragraph 3.2, Government Responsibilities will evaluate the contractor’s performance. The contractor’s QC program and the residual organization’s QASP should be complementary programs that ensure successful contractor performance.

Section 2: Performance Description Performance of the contractor will be monitored through the surveillance methods described in Section 4: Surveillance Methods to Perform Quality Assurance to assess the Contractor’s performance against PWS requirements.

2.1 Performance Standards and Acceptable Quality Levels (AQLs) For selected activities in the PWS, the PRS provides a performance standard and an AQL. A performance standard is the expected level of contractor performance. An AQL defines the level of performance that is satisfactory. Depending on the service evaluated and the evaluation method selected, performance standards and AQLs may be stated as a number of occurrences or as a percentage. Performance standards and AQLs for random sampling and 100 percent inspection are generally stated as percentages. For periodic inspections, performance standards may be stated as either percentages or as absolute numbers.

The contract requires the Contractor to perform all work as specified. Any inaccuracies or omissions in services or products are referred to as “defects” on the part of the Contractor. The Contractor shall be responsible for all identified defects and may be required to perform the work at no cost to the government. The AQLs take into account that in some instances an allowable level of deficiencies (deviations) is possible while overall performance continues to meet the government’s desired level of service.

2.1.1 Allowable Deviation

The AQLs define the level or number of performance deficiencies the Contractor is permitted to reach under this contract. AQLs take into account the difference between an occasional defect and a gross number of defects. AQLs can be expressed as a percentage of or as an absolute number (e.g., three per month). There may be instances where 100 percent compliance is required, and no deviation is acceptable (e.g., where safety is involved).

2.1.2 Substantially Complete

In some cases, service outputs are evaluated using subjective values (e.g., excellent, satisfactory, unsatisfactory). The criteria for acceptable performance and for defects must be defined for these service outputs. The concept of “substantially complete” should be the basis for inspections based on subjective scales. Work is considered “substantially complete” where there has been no significant departure from the terms of the contract and no omission of essential work. In addition, the Contractor has performed the work required to the best of its ability and the only variance consists of minor omissions or deficiencies.

2.2 Non-Performance

Non-performance occurs when the contractor’s performance does not meet the AQL for a given requirement.

Requirements may contain multiple performance elements, and therefore, deficiencies may occur in one or more aspects of performance (e.g., timeliness, accuracy, completeness, etc.) or subject areas of effort.

When surveillance indicates that the contractor's service output is not in compliance with the contract requirements, the Contracting Officer’s Representative (COR) must determine whether the Contractor or the Government caused the deficiency. If the cause of the defect rests with the Government, corrective action must be taken through Government channels. If the cause of the defect is due to action or inaction by the contractor, the contractor is responsible for correction of the problem at no additional expense to the Government.

2.2.1 Documentation

Documentation of work non-performed or unacceptable work is essential for tracking Contractor performance. The COR will document deficient work by compiling facts describing the inspection methods and results and to substantiate nonconformance with the contract. A sample documentation reporting form is provided in Appendix B Discrepancy Report. The documentation, with any recommendations, will be forwarded to the CO. In the case of the Contractor, the COR will decide whether to elevate the problem to the CO for corrective action.

2.2.2 Remedial Actions

The Federal Acquisition Regulation allows for penalties in the event that the Contractor fails to perform the required services. Penalties are defined as those actions taken under the direction of the CO against the contractor within the general provisions of the contract for nonconformance to the PWS and PRS.

Section 3: Contractor and Government Responsibilities

3.1 Contractor Responsibility

The Contractor is responsible for delivering products or services in accordance with the contract. Implementing its QCP, which describes the Contractor’s methods for ensuring all products and services under the contract meet established performance standards and AQLs. Maintaining, and providing for audit, quality control records and reports and all records associated with the investigation and complaint resolutions. Appointing a single quality control point-of-contact to act as a central recipient of communication from the COR or CO.

3.2 Government Responsibility

3.2.1 Contracting Officer (CO)

The CO is responsible for administering and monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by COR and the contractor’s performance. The CO may delegate various day-to-day contract administration duties to a Administering ACO (ACO) and/or the COR for performance management and administrative actions such as invoice approval and issuance of Contract Discrepancy Reports may be, and normally are, delegated by the CO to the COR. The CO shall approve any revisions to the QASP processes or standards.

3.2.2 Contracting Officer Representative (COR)

The COR, is designated in writing, by the CO. The COR will ensure that the QA function is properly executed, plays a key role in contract administration and performs the contract surveillance and monitoring. Some key contract administration duties include, but are not limited to, performs surveillance as required by this QASP; make recommendations to the CO for issuance of Contract Discrepancy Reports or letters of commendation and acceptance or rejection of completed work and for administrative actions based on unsatisfactory or non-performed work, and revisions or changes to the QASP;

and assists the CO in identifying necessary contract modifications and preparing reports of Contractor performance and cost.

The COR may use the form(s) included in the Appendices to perform the inspection or other forms as approved by the CO. The Contractor overall guidance is also provided by FAR clause 52.209-7 Information Regarding Responsibility Matters (OCT 2018) in Section E of the contract.

3.2.3 Customers

Insert this Section if applicable Customers or organizations/offices that the Contractor provided support may be requested to assist the COR in conducting QA to provide information relating to the Contractor’s performance through Customer Feedback.

Information gained from the Customer Feedback may be used in conjunction with other methods of observation to rate the performance of the Contractor.

Section 4: Surveillance Methods to Perform Quality Assurance

4.1 Surveillance Methods

The surveillance methods used in the QA process are the Government’s tools to monitor the Contractor’s products and services. The best means of determining whether the Contractor has met all contract requirements is to inspect the Contractor’s service products and analyze the results. Further, documented inspection results are an effective tool in contract administration that can confirm the successful achievement of all performance requirements or highlight areas where defects exist and improvements are necessary.

Explain how the PRS method of surveillance will be measured.

Surveillance: The Contracting Officer’s Representative, technical monitor, or Project Manager will be on site for all of the Delivery Items specified in the IDIQ. The aforementioned will also be monitoring the deliverables on a periodic basis. Please see Appendix A.

Standards: 90-95% of all work must be able to meet the standards and objectives on each line item outlined in the Schedule of Items. If adhering to policy it needs to be 100% met. The COR will notify the Contracting Officer for appropriate action in accordance with FAR 52.212.4, Contact terms and Conditions- Commercial Items or the appropriate Inspection of Services clause, if any of the above standards can not me met.

Procedures: The Technical Monitor or Project Manager that observes unacceptable standards as either incomplete or not performed, for any of the above performance standards that adhere to the specific schedule of items should immediately contact the COR and the COR will complete appropriate documentation and immediately talk with the contractor to rectify the issue. The COR will consider nature of the issue and could request a stop work order from the Contracting Officer if the violation is a safety matter. The Technical Monitor should inform the contractor of the approximate time the unacceptable performance will be corrected and will advise the COR. If not corrected, the COR will immediately talk to the contractor as this could result in a safety matter. The Technical Monitor will fill out a performance evaluation at the end of the BPSA, review this with the contractor, and submit to the COR. The Contracting Officer will receive the original and the COR will add the performance to CPARS database. Please see Appendix A.

Performance Requirements Summary.,

4.2 Analysis and Results

When the inspections and validations have been completed, the COR will perform an analysis of the Contractor’s performance. The purpose of the analysis is to ensure Government is receiving high-quality products and services from the Contractor. The COR will review the results, rate the Contractor’s compliance with the performance standards and AQLs, and characterize the Contractor’s overall performance. Analysis of all types of contract monitoring will result in one of the following outcomes:

[THIS PAGE IS FOR INFORMATIONAL PURPOSES]

The Contacting Officer must include as attachments or exhibits the appropriate performance requirement summary, forms, checklists, etc. in the QASP that will be used during surveillance / monitoring for the applicable contract.

Appendix A: Performance Requirement Summary

Performance

Task

Performance Standard

Acceptable Quality

Level (AQL)

Method of Surveillance

Incentive (+ /-)

Impact on Contractor Payment

Integrated Prescribed Fire Development and Delivery (Items 1 and 2)

•Assist and/or coordinate logistics of training and incident activity events.

•Ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

•Provide delivery in the most successful format for the learning outcome given the environment constraints.

•Provide subject matter expertise.

•Provide subject matter experts and or professors to the workshop

•Facilitate training and education activities or incident management to meet defined outcomes and objectives. These activities include:

workshops, after action reviews, conferences, meetings, guest speaking, staff rides, etc.

•Assist and/or coordinate logistics of training, education, or remote incident support.

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

•Delivery is consistent with the curriculum requirements and meets NWCG policy and Forest Service direction.

•Instructors are prepared and knowledgeable in the training and education material.

•Logistics are pre-planned and coordinated in advance of the event. Event is not disrupted by preventable logistical issues.

•Requested facilitation outcomes and objectives are accomplished.

•Logistics are pre-planned and coordinated in advance of the event.

Event is not disrupted by preventable logistical issues.

• COR, Technical Monitor or Project Manager will be periodically monitoring the development of the Burn Boss Workshop and will conduct on-site monitoring presentations and communication for the delivery portion of the Burn Boss Workshop.

• The Contractor’s quality will be reflected in the performance assessment either as positive or negative incentive.

• If the

Contractor fails to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or will not be allowed to participate in the optional years of the

IDIQ.

• If quality does not meet standard, pay deduction and/or additional costs to the Government will be assessed.

Burn Plan Review (Item 3)

• Ensure that the Prescribed fire plans meet agency policy and direction

• Ensure complexity analysis accurately represents the project.

• Provide concurrence with the calculated

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

•Delivery is consistent with the curriculum requirements and meets

• COR, Technical Monitor or Project Manager will be periodically monitoring the Burn Plan Review and could be on calls to ensure if the overall performance standards are being met.

• The Contractor’s quality will be reflected in the performance assessment either as positive or prescribed fire complexity determination

• Ensure that the prescription parameters by fuel type is realistic in meeting the resource objectives

• Ensure that the ignition holding, and contingency plans are consistent with the predicted fire behavior and fuel types inside and outside of the planned ignition units

• Participate in prescribed fire reviews and technical reviews of burn plans

NWCG policy and Forest Service direction.

• Instructors are prepared and knowledgeable in the burn plan template and know how to develop a burn plan based on the newest burn plan template. Give recommendations to the Burn Plan preparer and Burn Boss to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or will not be allowed to participate in the optional standard, pay deduction and/or additional costs to the Government will be assessed.

RT-300

Development and Delivery (Items 4 and 5)

• Ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

• If in person workshop is requested, assist R4 personnel with delivery logistics to include evaluating hotels and meeting facilities to ensure compliance with Americans with Disabilities Act requirements, agency regulations, and adequacy to provide a professional training delivery.

• If a virtual workshop is requested, assist R4 personnel with delivery logistics to include workshop facilitation, documentation of attendance, and recording of workshop.

• Coordinate with various presenters and/or

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

• Develop curriculum to ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

• Logistics are pre-planned and coordinated in advance of the event. Event is not disrupted by preventable logistical issues.

• Contractors shall update training within 7 business days of being provided updated information. This needs to be worked together by the COR, Technical Monitor or the Project Manager.

• Requested facilitation outcomes and

• COR, Technical Monitor or Project Manager will be periodically monitoring the Burn Plan Review and could be on calls to ensure if the overall performance standards are being met.

• The Contractor’s quality will be reflected in the performance assessment either as positive or to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or will not be allowed to participate in the optional cooperators on content of their planned presentations.

Eliminate duplications between presentations and ensure critical teaching points are included.

• Present curriculum of topics pertinent to participants and the agency. Contractor shall develop and make formal presentations at a very professional level on current issues and topics. Real life experience and understanding of the political environment is a must in the presentation development.

• Facilitate classroom and small group discussions, opening and close-out presentations, daily planning, logistical support, marketing, and documentation needs for the Intermountain Region.

objectives are accomplished.

not meet standard, pay deduction and/or additional costs to the Government will be assessed.

Development and Delivery Burn Plan Writing Workshop (Item 6)

• Ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

• Topics/elements will be based on the current need as determined by R4 personnel.

• If in person workshop is requested, assist R4 personnel with delivery logistics to include evaluating hotels and meeting facilities to ensure compliance with Americans with Disabilities Act requirements, agency regulations, and adequacy to provide a

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

• Develop curriculum to ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

• The COR, Technical Monitor or Project Manager with work with the vendor on topics and elements from the Forest or Region performing this task.

• Logistics are pre-planned and coordinated in advance

• COR, Technical Monitor or Project Manager will be periodically monitoring the Burn Plan Review and could be on calls to ensure if the overall performance standards are being met.

• The Contractor’s quality will be reflected in the performance assessment either as positive or to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or professional training delivery.

• If a virtual workshop is requested, assist R4 personnel with delivery logistics to include workshop facilitation, documentation of attendance, and recording of workshop.

of the event. Event is not disrupted by preventable logistical issues.

will not be allowed to participate in the optional standard, pay deduction and/or additional costs to the Government will be assessed.

Facilitated Learning Analysis Review (Item 7)

• Ensure adherence with agency and NWCG policy direction this standard needs to be met 100%.

• Work with the FLA Team Leader and other FLA positions to ensure everyone has an basic understanding of just culture and a basic understanding of the FLA Process.

• The FLA Team Leader will provide roles and responsibilities to vendor.

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

• With the aid of the COR will work with the FLA Team Leader. Once contact has been established. The Team Leader will work with the vendor until FLA is completed. COR will get with the FLA Team Leader to depict if the vendor position has been met for the FLA.

• Vendor will provide recommendations based on the role they are in. FLA Team Leader will ensure vendor meets this for completion of the

FLA.

• The Contractor’s quality will be reflected in the performance assessment either as positive or to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or will not be allowed to participate in the optional standard, pay deduction and/or additional costs to the Government will be assessed.

Burn Boss Workshop Development and Delivery (items 8 and 9)

•Assist and/or coordinate logistics of training and incident activity events.

•Ensure adherence with agency and NWCG policy

• A quality level of 90 to 95 percent is warranted for all bullet points, minus NWCG policy and Forest Service Policy which is 100% no exceptions.

• COR, Technical Monitor or Project Manager will be periodically monitoring the development of the Burn Boss Workshop and will be on site to

• The Contractor’s quality will be reflected in the performance assessment either as direction this standard needs to be met 100%.

•Provide delivery in the most successful format for the learning outcome given the environment constraints.

•Provide subject matter expertise.

•Provide subject matter experts and or professors to the workshop

•Facilitate training and education activities or incident management to meet defined outcomes and objectives. These activities include:

workshops, after action reviews, conferences, meetings, guest speaking, staff rides, etc.

•Assist and/or coordinate logistics of training, education, or remote incident support.

•Delivery is consistent with the curriculum requirements and meets NWCG policy and Forest Service direction.

•Instructors are prepared and knowledgeable in the training and education material.

•Logistics are pre-planned and coordinated in advance of the event. Event is not disrupted by preventable logistical issues.

•Requested facilitation outcomes and objectives are accomplished.

•Logistics are pre-planned and coordinated in advance of the event.

Event is not disrupted by preventable logistical issues.

monitor presentations and communication for the delivery portion of the Burn Boss Workshop.

positive or to meet standards identified in the Call Order, work may be suspended or put in Default for failure to take corrective action immediately, result in adverse performance assessment or will not be allowed to participate in the optional standard, pay deduction and/or additional costs to the Government will be assessed.

Appendix B: Discrepancy Report The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

DISCREPANCY REPORT 1. DISCREPENCY REPORT NO.

2. TO: (Contractor / Project Manager Name) 3. FROM: (Name of COR)

CONTRACT NUMBER: DATE:

PREPARED ORAL NOTIFICATION RETURNED BY CONTRACTOR ACTION COMPLETE

4. DISCREPENCY OR PROBLEM (Describe in Detail. Include PWS references. Attach Continuation Sheet if Necessary)

5. SIGNATURE OF COR

6. TO: (Name of COR) 7. FROM: (Contractor / Project Manager)

8. CONTRACTOR RESPONSE AS TO CAUSE, EFFECT, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE (Attach Continuation Sheet if necessary. Cite applicable Contractor QC program procedures or new QC procedures)

9. SIGNATURE OF CONTRACTOR REPRESENTIVE 10. DATE

11. GOVERNMENT EVALUATION (Acceptance, partial acceptance, or rejection. Attach Coordination Sheet if necessary)

12. GOVERNMENT ACTIONS (Cure notice, show cause, other)

CLOSE OUT

KTR NOTIFIED

NAME AND TITLE SIGNATURE DATE

COR

Appendix C: Customer Feedback Record The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

CUSTOMER FEEDBACK RECORD

DATE AND TIME OF COMPLAINT CONTRACT NUMBER/ OR PROJECT:

SOURCE OF COMPLAINT

ORGANIZATION

INDIVIDUAL

NATURE OF COMPLAINT

PWS REFERENCE

VALIDATION

DATE AND TIME CONTRACTOR INFORMED OF COMPLAINT NAME OF CONTRACTOR REPRESENTATIVE INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR (Responsible officer):

RECEIVED AND VALIDATED BY

Determination: Complaint Valid Complaint Invalid

Appendix D: Example Guide / Inspection List The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

CONTRACT NUMBER: ___________________________________

SERVICE FUNCTION:

PWS SECTION:

1 Method of Surveillance:

2 Lot Size:

3 Sample Size:

4 Performance Requirement: Performance is Excellent (E) when ___________or fewer defects are discovered per month. Performance is Satisfactory (S) when ________ or fewer defects are discovered per month. Performance is Unsatisfactory (U) when _______ or more defects are discovered per month.

5 Sampling Procedure: Instructions on how to select the sample must be clear and complete

6 Inspection Procedure: The procedure must be detailed enough to allow a yes/no objective decision as to the acceptability of performance by anyone making the inspection. Explain when evaluation is to occur and what is acceptable/unacceptable

Performance: Excellent (E), Satisfactory (S), Unsatisfactory (U), Not Applicable (N/A)

PRS Requirements Timeliness Quality of Work Notes

Overall Rating Of Inspection (E, S, U or N/A)

COR/Inspector Comments:

Contractor Signature: ___ Date: __

COR Signature: ____________________Date: _________________

Appendix E: Example Quality Assurance Monitoring The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

CONTRACT NUMBER: ______________________________________

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check the applicable item):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint

LEVEL OF SURVEILLANCE (Check the applicable item):

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 the applicable item):

Meets Standards

Does Not Meet Standards

Narrative of Performance During Survey Period:

Prepared By: _______________________________ Date: ______________

Appendix F: Example Customer Complaint Investigation The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

CONTRACT NUMBER: _________________________

SERVICE or STANDARD:

SURVEY PERIOD: ___________________

DATE COMPLAINT RECEIVED: ____________

SOURCE OF COMPLAINT: _________________________________________ (Name) _______________________________________________________________ (Organization) ___________________ (Phone No.) _________________________________ (Email Address)

NATURE OF COMPLAINT:

RESULTS OF COMPLAINT INVESTIGATION:

DATE SERVICE PROVIDER INFORMED OF COMPLAINT: _____________

CORRECTIVE ACTION TAKEN BY SERVICE PROVIDER:

Received and Validated By: __________________________________________ Prepared By: _____________________________ Date: _________________

Appendix G: Example Surveillance Activity Checklist The following document is only an example, which is not all inclusive, that can be revised and used, if applicable, in the QASP as attachments or exhibits.

Performance Requirement

Performance Standard

Method of Measurement

Performance Metrics

Method of Surveillance

Date Accomplished

Compliance (Exceed, Met, Partial Met)