Exhibit 3 GSA Surveillance Forms 2021 08 23.pdf

SAMPLE

CONTRACT CLEANING INSPECTION REPORT

INSTRUCTIONS: Form is used for inspection of contract cleaning by inspectors to record results. The condition of area(s) inspected will be rated SATISFACTORY or UNSATISFACTORY. Explain unsatisfactory rating in remarks column and complete quantity column.

BUILDING Report NO. CONTRACT NO.

450 Golden Gate GS-09-06-KSD-0000

INSPECTOR (Print Name) INSPECTOR'S

SIGNATURE

JOHN DOE

TIMED STARTED TIME COMPLETED DATE OF INSPECTION

9:00 A.M. 10:50 A.M. 10/31/06

INTERVIEWED BY CONTRACTOR'S RECEIPT TIMEDATE

DATE

MS. DEE 11/01/06 sup. signature 1:00 p.m. 11/01/06

WORK DESCRIPTION – CHECK ONEQUANTITYLOCATION REMARKS

(Room No., Corridor, lobby, or either) UNSAT.SAT.

By Measure or count .

3rd Floor East

M3-5171 X Rust on toilet base under bolt of toilet

3-5178 X

Women's Public Restroom X

Men's Public Restroom

-M-7665 X Slight build up in corners of urinal

Drinking Fountains X Mineral Build up

-1st near room 1-5566

This form shall be filled out and submitted to the Contractor when deficiencies are found during the COR's inspections.

This form can be found at: GSA Insite/Financial Transactions/GSA Forms Library

EXHIBIT 3 – SURVEILLANCE FORMS

GSA Form 1181A – Contract Cleaning Inspection Report

GENERAL SERVICES ADMINISTRATION GSA FORM 1181A

SAMPLE

QASP MONTHLY INSPECTION REPORT

BUILDING NAME & LOCATION: 58 Pearl Street Burlington

CONTRACT NO.: ______________GS-09P-06-KSD-0000__

CONTRACTOR NAME: ____XXX Cleaning Service____

Please report all deficiencies found during the previous month inspection(s). Attach copies of all GSA 3539 Forms submitted to the contractor with this form. If there were no deficiencies, please submit this form indicating there were no deficiencies reported for the month. This form will become a part of the official QA documentation.

DEFIENCIES & CORRECTIVE ACTIONS COMMENTS

Documented on the Contract Cleaning Inspection Reports

All Deficiencies Minor, Corrected by the Contractor

COR

Signature: _________________ Date: _________________

COR’s Checklist for Inspections

CUSTODIAL AND RELATED SERVICES COMMENTS

Submittals:

-a list of names and telephone numbers of on-site supervisors -security clearance documentation (current & new employees)

- work schedules

- floor maintenance schedules

- SDS documentation

- initial IPM inspection report

Quality Control Plan (QCP)

- description of training programs

- description of disciplinary procedures

- description of contingency plan for separation of employees

Inspection Reports

Service Call Logs

Tenant Reports

Integrated Pest Management (IPM) Quarterly Reports

Recycling and Solid Waste/Trash Hauling Reports

NOTE: This checklist does NOT represent an all-inclusive list of items that may be reviewed during an inspection. It is provide ONLY as guidance for the CO or their designee.