Attachment_J.4_Example_Service_Request_Form.pdf

ATTACHMENT J-4

Example Service Request Form

Service Request and Completion Form This form is used to communicate and track all activity related to each service request.

Box 1. Service request

- This section is to be completed by the FDA instrument point-of-contact (POC).

- Email the form as an attachment to the contractor manager

- Contractor handles the process next. If approved, you will use a fully-completed version to close out service (see Box 5).

Request Center COR(s) Date

Boxes in red will accept free text

OEM – original equipment mfr

Instrument model (name and/or number)

Servicing Vendor: Repair Provider or OEM points of contact (name, address, phone email)

Instrument location (street address, state, ZIP)

Instrument POC (requestor’s name, phone, & email)

Service Type

Describe problem or service requested.

Contractor will follow up

FDA Barcode

Instrument serial number

Service level

Instrument type

Box 2. Instructions to contractor, upon receipt from instrument POC:

- Verify items in Box 1, contact specified servicing vendor for quote if a T&M service, attach quote to form, add comments, save entries.

Email form as an attachment to

FDA POC

Contractor comments

Is quote attached?

Estimated cost

Box 3. Instructions to contracting officer's representative (COR) upon receipt from contractor: - Select approval status, select COR name, give a not-to-exceed value, and submit comments.

Approved by COR or designee?

COR comments and instructions

Center COR giving approval

NTE $

(not to exceed)

Box 4. Instructions to contractor upon receipt from FDA COR:

- Enter PO number, attach PO to this form, submit comments, and send form to the instrument POC with a copy to the

FDA COR.

Contractor Contractor Purchase Order #

(PO) comments

Box 5. Instructions to instrument POC Immediately after service is complete:

- Fill in this section and click the appropriate button to email your Center COR(s) and contractor that the service was complete, attach the field service report if available, and give an assessment of the service.

The instrument service is complete

The service engineer gave FDA a copy of the field service report (FSR).

Provide details if instrument service was not satisfactory.

After completing Box 5, click the button for your organization to pop open an email addressed to the appropriate people.

This PDF form will be automatically attached. Please put the PO number in the Subject Line and click Send.

Thanks!

The instrument service was satisfactory

Date Service completed

If FDA received a copy of the FSR, an electronic copy is attached.

ORA – ORS Users: Submit by Email

ORA –ORS ORM – PM Users: Submit by Email

Box 6. Instructions to contractor upon receipt of a form completed through Box 5, but lacking an FSR:

- Reach out to the servicing vendor identified on page 1, and obtain a copy of the field service report (FSR).

- Email the FSR with this form to the POC and COR, by selecting the appropriate "submit by email" button above.

- For reference select the designation shown in Box 1A on page 1.

☐ Contractor obtained the FSR from the servicing vendor. It is attached to this email.

USER INSTRUCTIONS

This form will expedite service processing, improve communication, and enable assessment of customer satisfaction under the FDA's contract for instrument services.

INSTRUCTIONS to instrument POC:

The process under which this contract operates requires that FDA immediately notify both contractor and your Center COR that the service has been completed and whether it was satisfactory.