Exhibit C3 Surveillance Forms.pdf

EXHIBIT JC3

SURVEILLANCE FORMS

GSA FORM 1181A - CONTRACT CLEANING INSPECTION REPORT

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

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 ratings in the REMARKS column and complete the QUANTITY column.

BUILDING REPORT NO. CONTRACT NO.

INSPECTOR (print name) INSPECTOR'S SIGNATURE DATE OF INSPECTION

TIME STARTED TIME COMPLETED

CONTRACTOR RECEIPT

CONTRACTOR (print name) CONTRACTOR'S SIGNATURE Time Date

WORK DESCRIPTION - Quantity Check One

LOCATION (Room no., (by measure REMARKS corridor, lobby, etc.) or count) SAT UNSAT

Room 3-5171 1 ea X Rust on toilet base around bolt

Room 3-5178 X

5th floor ladies' public toilet room X

5th floor mens' public toilet room 750 sf X Buildup on floor in corners around urinal

1st floor lobby drinking fountain 250 sf X Mineral buildup on bubbler

GENERAL SERVICES ADMINISTRATION GSA FORM 1181-A

Exhibit C3

QASP Monthly Inspection Report

BUILDING NAME & LOCATION: Phillip Burton Federal Building & US Courthouse

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 Form 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.