RFP 70FB8025R00000001 Attachment 5 Section J Admin Forms 20240924.pdf

ATTACHMENT 4

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Section J: LogHOUSE Administration Forms and Templates

Table of Contents Administration Attachments – 1000

Attachment 1001, Daily Report to the COR [C]

Attachment 1002, Invoice Report [C]

Attachment 1003, Required Contractor Availability [C]

Attachment 1004, Past Performance Questionnaire [C]

Attachment 1005, Mission Scope of Work [C]

Attachment 1006, Contractor Monthly Report [C]

Attachment 1007, Management Quality Assurance Plan (QASP)[C]

Attachment 1008, Weekly Quality Control Report [C]

Attachment 1009, TTHUM Scope [C]

Staging Attachments – 1100

Attachment 1101, Staging Report on Unsuitable TTHUs [C]

Attachment 1102, Staging Operation Report [C]

Site Inspection Reports (SIRs) Attachments -1200

Attachment 1201, Site Feasibility Inspection Status Report [C]

Attachment 1202, Site Feasibility Inspection Report [C]

Attachment 1203, Commercial/Group Site Feasibility Report [C]

Attachment 1204, Right of Entry [GFI] [C]

Attachment 1205, SIR Quality Assurance Plan (QASP) [C]

Haul & Install Attachments – 1300

Attachment 1301, Installation Status Report [C]

Attachment 1302, RFO Checklist – Manufactured Homes [C]

Attachment 1303, RFO Checklist – Travel Trailers [C]

Attachment 1304, Release of Installation Material [C]

Attachment 1305, Installation Appendix [C]

Attachment 1306, FEMA TTHU Transfer Inspection Form [C]

Attachment 1307 – Individual Installation Report [C]

Attachment 1308 – RFO Quality Assurance Plan (QASP) [C]

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Tank and Pump System (TPS) Attachments – 1400

Attachment 1401, Required Qualifications (TTHU Sprinkler System and Tank and Pump System (TPS) [C]

Attachment 1402, Tank and Pump System (TPS) Visual Inspection Checklist

TTHU Maintenance Attachments – 1500

Attachment 1501, Call Center Log [C]

Attachment 1502, Preventative Maintenance & Repair Schedule [C]

Attachment 1503, Maintenance Summary Report [C]

Attachment 1504, Individual Maintenance Report [C]

Attachment 1505, Weekly Pre-Priced Repairs Summary Request [C]

Attachment 1506, Preventative Maintenance Inspection Log [C]

Attachment 1507, TPS Monthly Maintenance Checklist [C]

Attachment 1508, TTHU Maintenance Pre-Priced Repairs Request [C]

Attachment 1509, Maintenance Quality QASP [C]

Attachment 1510, PMI Quality QASP [C]

Group Site Maintenance Attachments – 1600

Attachment 1601, Group Site Maintenance Inspection Log [C]

Deactivation Attachments – 1700

Attachment 1701, TTHU Deactivation Checklist [C]

Attachment 1702, Deactivation Summary Report [C]

Attachment 1703, Individual Personal Property Inventory [C]

Attachment 1704, TTHU Pre-Deactivation Checklist [C]

Attachment 1705, Former Occupant Personal Property Inventory [C]

Attachment 1706, Deactivation Quality Assurance Plan (QASP) [C]

Construction Attachments – 1800

Attachment 1801, Definable Features Internal Checklist [F] [C]

Attachment 1802, Definable Features Checklist – Staging [F] [C]

Government Furnished Information (GFI) General Attachments – 1900

Attachment 1901, Glossary of Terms [GFI]

Attachment 1902, Contractor Personnel Access Requirement [GFI]

Attachment 1903, Performance Evaluation Calculator [GFI]

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Attachment 1904, Technical Scenario Answer Template [GFI]

Attachment 1905, TTHU Identification Locations [GFI]

Attachment 1906, Typical Tools [GFI]

Attachment 1907, Acronyms [GFI]

Attachment 1908, Personnel Competencies and Requirements [GFI]

Attachment 1909, Wrap-Around Services Planning [GFI]

Attachment 1910, FEMA MHU Clean for Reuse Procedures Revision AA – August 18, 2017 [GFI] 179

Attachment 1911, VAMC Carpet Care SOP [GFI]

Attachment 1912, VAMC Door Cleaning and Polishing SOP [GFI]

Attachment 1913, VAMC Equipment Care and Cleaning SOP [GFI]

Attachment 1913, VAMC Floor Care SOP [GFI]

Attachment 1914, VAMC Heat Convectors, Radiators and Vent Cleaning SOP [GFI]

Attachment 1915, VAMC Light Fixture Cleaning SOP [GFI]

Attachment 1916, VAMC Mini-Blind Cleaning SOP [GFI]

Attachment 1917, VAMC Patient Room Cleaning SOP [GFI]

Attachment 1918, VHA Cleaning Agents [GFI]

Attachment 1919, VHA Cleaning Supplies and Equipment Listing [GFI]

Attachment 1920, VHA Infection Control Program [GFI]

Attachment 1921, VHA Sanitation Safety Plan [GFI]

Attachment 1922, VHA Standards of Cleanliness [GFI]

Government Furnished Information (GFI) Staging Attachments – 2000

Government Furnished Information (GFI) Transportation Attachments – 2100

Government Furnished Information (GFI) Site Inspection Attachments – 2200

Attachment 2201, Design, Construction and Staging Appendix [GFI]

Attachment 2202, FEMA EHP Compliance Review Requirements - Ensuring Timely EHP Review for Direct Housing Missions, 2022-2023 Memo [GFI]

Government Furnished Information (GFI) Installation Attachments – 2300

Attachment 2301, FEMA NexGen MHU Installation Manual – 2/16/2021 Rev.1 [GFI]

Attachment 2302, TTHU Ramp Configuration [GFI]

Attachment 2303, TTHU Ramp Slope [GFI]

Attachment 2304, Installation Appendix [GFI]

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Attachment 2305, Uniform Federal Accessibility Standards (UFAS) Ramp Construction [GFI]

Government Furnished Information (GFI) TPS Attachments – 2400

Attachment 2401, TANK AND PUMP SYSTEM (Manual) – FMTPS002 – Darley – 10.17.16 [GFI] 22

Attachment 2402, TALCO FIRE SYSTEMS – TALCO FEMA TPS INSTALLTION, OPERATION and MAINTENANCE MANUAL [GFI]

Attachment 2403, General Air Tank & Pump System for FEMA – Installation, Operation and Maintenance Manual, Internal TPS Version 4 [GFI]

Attachment 2404, General Air products Tank and Pump System for FEMA – Alarm Bar Installation Addendum – 1/24/17, Revision BB_05 [GFI]

Attachment 2405, MHU Fire Sprinkler System Installation, Test, Maintenance, Repair and Deactivation Guide [GFI]

Attachment 2406, Tank and Pump System (TPS) Acceptance Test Procedures, Rev. 1, July 6, 2017

[GFI]

Attachment 2407, Internal Tank and Pump System (TPS) Acceptance Test Procedures, June 13, 2024

[GFI]

Government Furnished Information (GFI) Maintenance Attachments – 2500

Attachment 2501, Work Order [GFI]

Attachment 2502, Discrepancy Report [GFI]

Attachment 2503, PMI Questionnaire [GFI]

Attachment 2504, Wear/Non-Wear items [GFI]

Attachment 2505, Pre-Priced Repairs Pricing List [GFI]

Government Furnished Information (GFI) Deactivation Attachments – 2600

Attachment 2601, DOJ Deactivation Scope [GFI]

Government Furnished Information (GFI) Construction Attachments – 2700

Government Furnished Information (GFI) Design Attachments – 2800

Government Furnished Information (GFI) Group Site Maint. Attachments – 2900

Government Furnished Information (GFI) Proposals Attachments – 4000

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Summary:

Section J, LogHOUSE Administration Forms and Templates provides forms/templates to the Contractors to facilitate data collection and analysis by FEMA.

All provided forms /templates in Section J are for reference and they may be replaced during the life of the contract. In the event that a form/template has to be replaced/updated, FEMA designated personnel will provide the respective form/template to the Contractor.

Templates are categorized by a letter designation as follows:

Government Furnished Information [GFI] - This information is provided to the Contractor for informational purposes only.

Contractor Form [C] - This form shall be completed by the Contractor and submitted to FEMA.

FEMA TO/WO Form [F] - This form will be provided to the Contractor as part of a Task/Work Order. These forms will contain details about the Task Order/Work Order.

Proposal Only [P] - These attachments are only part of the proposal; they will not accompany the Contract. The attachments could be standalone and require various actions or they could be a supplement to a Section in the contract.

Combination - These are forms that meet two or more categories above. This will include the applicable letter for each definition.

All forms will be in two formats - digital and/or in this document - submission requirements are

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Administration Attachments – 1000

Attachment 1001, Daily Report to the COR [C]

Daily Report to the COR Declared Disaster XXXX - Location

DATE: XX/XX/XXXX

Person Reporting:____________________________ Signature:______________________________________

1. Operations:

Safety (address any safety issues or concerns)

Key Personnel:

Name Location Arrival Date Departure Date

2. Activities Today’s events 1.

2.

3.

4.

Planned for Tomorrow 1.

2.

3.

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4.

3. Haul and Install Status Chart

Address Haul/Install Activities: (date, work completed) blocking, electrical, HVAC, plumbing, stairs, system check, RFO ready

WO Number WO Issued

Installations Completed Today

Installations Cumulative Total

Current Issues

4. Monthly Preventive Maintenance Inspections and Repair (PMIR):

Previous period: through _______________

Previous Period This Period Total

This period: ___________________ Required Complete – Unit OK

Complete – Repair

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5. Maintenance:

Maintenance Emergency Through COB Emergency

Cumulative Total Routine Through COB Routine Cumulative Total

Calls Received Calls Completed

Calls Overdue

6. Deactivations:

Deactivations Emergency Through COB Emergency

Cumulative Total Routine Through COB

Emergency Cumulative Total

Grand Total

Calls Received

Calls Completed

Calls Overdue

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7. Contractor Points of Contact:

Contacts Office Phone Mobile Phone E-Mail

8.

Weather

The Contractor shall report current and forecasted weather. In addition, the Contractor shall report any issues due to current or future weather and how it is going to affect operations.

Current Weather Forecast Weather Issues due to Weather Time Affected Area ( Specific or Entire Operation)

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Attachment 1002, Invoice Report [C]

INVOICE REPORT

Contractor Name Address

FEMA Declared Disaster #

Time Period

Total Work Orders Invoiced

Total Amount

Invoiced $0.00

Work Order Number

Work Order Description Invoice Number

Invoice Date Invoice Total Comments

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Attachment 1003, Required Contractor Availability [C] For purposes of this contract, Contractor availability is defined as able to carry out all of the requirements of the applicable sections of the contract. Contractors may choose to have staff available earlier. Time extensions that cause a delay in Contractor availability must be approved in advance by FEMA.

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Attachment 1004, Past Performance Questionnaire [C]

PAST PERFORMANCE QUESTIONNAIRE

The Department of Homeland Security (DHS), FEMA, recently released a Request for proposal for the procurement of supplies or services RFP #HSFE80- 16-R-0004. Offerors were asked to provide information on contracts similar in nature, size and complexity to the present requirement on which they had performed in the past. An offeror has submitted this to you as a reference for past performance. (See blocks 1 to 3 below).

We need your opinion on how well the contractor performed on your contract(s). Please fill out the attached questionnaire and send it electronically to the Contracting Officer at Rahsaan.Edwards@fema.dhs.gov. To be considered, this form must be filled out and received by the contracting officer no later than the closing date and time listed in the request for proposal. DHS/FEMA may contact you to clarify or verify any information provided. For purposes of confidentiality, only send this completed form to the FEMA contracting officer.

Your input will be confidential. Please note your comments will be used to form the basis for evaluation of this offeror. Thank you in advance for your assistance. If you have any questions please contact Rahsaan Edwards, Contracting Officer at (202)646-5786 by email at rahsaan.edwards@fema.dhs.gov.

A. CERTIFICATION

By law, the Government will not disclose the names of individuals providing reference information during discussions with the contractor identified in Block 1 below.

Block 1. Contractor Name:

Block 2. Contractor phone number and address:

Block 3. Contract Name and Number: |

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS QUESTIONNAIRE IS

ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Evaluator’s Printed Name Title

Evaluator’s Mailing Address (Agency, Bldg/Room, Street, City, State, Zip)

Evaluator’s Signature Date Phone Fax

B. INSTRUCTIONS

Two forms are provided to document your opinion: 1) Performance Rating Form;

and 2) Supplemental Comment Form. Please fill out both forms in accordance with the instructions provided on each. Please use the following standards in arriving at your rating: 1) Superior – the contractor undoubtedly performed successfully in every aspect of the effort 2) Satisfactory – the contractor’s overall performance was successful but with some minor exceptions 3) Unsatisfactory – the contractor’s overall performance was unsatisfactory or 4) Not Applicable.

PERFORMANCE RATING FORM (put an X in the appropriate box)

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Performance Element Superior Satisfactory Unsatisfactory Not Applicable

1. QUALITY OF SERVICES: The contractor provided high quality of service and performed successfully.

2. EFFECTIVE AND EFFICIENT USE OF

RESOURCES: The contractor used an efficient number of resources e.g.

personnel, facilities and other resources to support the project. Use of subcontractors was appropriate in supporting the project.

3. COMMUNICATION: The contractor worked and communicated well with client management, staff, and contracting officials as well as with his or her own staff and subcontractors.

4. TIMELINESS OF PERFORMANCE:

The contractor planned and proposed realistic schedules, successfully monitored performance and completed work on time.

5. CUSTOMER SATISFACTION: The contractor exhibited a commitment to customer satisfaction and achieved customer satisfaction.

6. RESPONSIVENESS AND

ATTENTIVESNESS: The contractor exhibited reasonable and cooperative behavior in response to client changes, criticism/rejection of contract deliverables and in detecting and correcting errors, poor performance, and other problems.

7. COST CONTROL: The contractor successfully planned and proposed realistic costs and monitored performance, and consistently operated at or below budget.

8. SUBCONTRACTING PLAN: The contractor put forth good faith effort in meeting it small and disadvantaged business goals.

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9. TECHNICAL PROFICIENCY: The contractor demonstrated the highest level of technical proficiency required for completion of the task in a timely and successful manner.

10. RISK MANAGEMENT: The contractor was proactive and was able to overcome and mitigate any contract obstacles that surfaced.

OVERALL PERFORMANCE::

YES NO

11. Given the choice would you do business with this contractor again?

12. Did either you or the contractor have to resort to litigation to resolve problems?

Supplemental Comment Form

Please provide any additional comments regarding your performance element ratings in the appropriate spaces below. We appreciate your time and valuable comments. Please add additional pages as necessary.

Performance Element #1, Quality of Services:

Performance Element #2, Effective and Efficient Use of Resources:

Performance Element #3, Communication:

Performance Element #4, Timeliness of Performance

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Performance Element #5, Customer Satisfaction:

Performance Element #6, Responsiveness and Attentiveness:

Performance Element #7, Cost Control:

Performance Element #8, Subcontracting Plan:

Performance Element #9, Technical Proficiency:

Performance Element #10, Risk Management

Question #11, given the choice would you do business with this contractor again?

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Question #12, did either you or the contractor have to resort to litigation to resolve problems?

Additional Comments:

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Attachment 1005, Mission Scope of Work [C]

Included as an attachment in a separate file.

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Attachment 1006, Contractor Monthly Report [C]

Contractor Monthly Report

[DATE]

[Declared Disaster XXXX - Location]

Work Orders

Issued Complete Pending

Site Inspections

Installation

Maintenance

Demobilization

Total Work Orders 0 0 0

Delay Explanation:

Number of Units

MH PM TT

Units in Staging 0 0 0

Units Assigned 0 0 0

Units RFO 0 0 0

Units Occupied 0 0 0

Units Deactivated 0 0 0

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Total Number of Units 0 0 0

Staffing

Name, Role/Title Location Arrival Date Departure Date

Safety

Address any safety issues or concerns:

Monthly Preventive Maintenance Inspections (PMI):

Total For Month

Required

Complete – Unit OK

Complete – Repair

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Maintenance

Emergency Cumulative Total

Routine Cumulative Total

Calls Received

Calls Completed

Calls Overdue

Deactivations

Emergency Cumulative Total

Routine Cumulative Total

Calls Received

Calls Completed

Calls Overdue

Concerns and Issues

Contractor Concerns

FCO/IA Chief Concerns

Additional Activities or Issues

Site Feasibility Issues

Installation Issues

Maintenance Issues

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Demobilization Issues

Contractor Points of Contact

Contacts Office Phone Mobile Phone E-Mail

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Attachment 1007, Management Quality Assurance Plan (QASP)[C]

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Attachment 1008, Weekly Quality Control Report [C]

Weekly Quality Control Report

Location Date

Discovered

Identification of the

Deficiency

Suggested Remedies for Deficiency

Remedy Implementation

Date Comments

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Attachment 1009, TTHUM Scope [C]

Initial TTHUM SCOPE

(Scope can change during the mission)

Item Information Format Information

Disaster Number DR -

State

Date Declared

Counties Declared County Names

Item Information Format Variable

Joint Field Office (JFO) Address

City, State, ZIP

Area Field Office (AFO)

Add additional AFOs if needed Address

City, State, ZIP

Item Information Format Variable

Contracting Officer’s Representative

(COR)

Name, Number, Email

Field Contracting Officer (CO)

If assigned or known at time of Task Order Proposal Request

Name, Number, Email

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Staging Attachments – 1100

Attachment 1101, Staging Report on Unsuitable TTHUs [C]

Staging Report on Unsuitable TTHUs

Contractor Name

UNIT IDENTIFICATION

FEMA Declared Disaster # Unit Type Serial # Bar Code FEMA #

DAMAGE COST DAMAGE COST DAMAGE COST

KITCHEN HALLWAY BATHROOM (FULL)

RANGE HVAC (INTERIOR) COMMODE

RANGE HOOD / VENT FAN SMOKE ALARM TUB/SHOWER

REFRIGERATOR LIGHT FIXTURES SHOWER DIVERTOR

CABINETS LIGHT SWITCHES SINK / FAUCET

SINK / FAUCET FLOOR COVERING MIRROR

DRAWERS FLOOR VENTS LIGHT FIXTURES

LIGHT FIXTURES WALL PANELS OUTLETS

OUTLETS CEILING LIGHT SWITCHES

LIGHT SWITCHES WASHER/DRYER ALCOVE FLOOR COVERING

Fire Extinguisher MISC. FLOOR VENTS

SMOKE ALARM WALL PANELS

BLINDS/CURTAIN RODS FIRST BEDROOM CEILING

FLOOR COVERING DOUBLE BED EXHAUST FAN

FLOOR VENTS BUREAU MISC.

WALL PANELS MIRROR

CEILING CLOSET BATHROOM (3/4)

MISC. NIGHT STAND/BED SIDE TABLE COMMODE

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LIGHT FIXTURES SHOWER

DINING ROOM OUTLETS SINK / FAUCET

DINETTE TABLE LIGHT SWITCHES MIRROR

DINETTE CHAIRS BLINDS/CURTAIN RODS LIGHT FIXTURES

OUTLETS FLOOR COVERING OUTLETS

LIGHT SWITCHES FLOOR VENTS LIGHT SWITCHES

LIGHT FIXTURES WALL PANELS FLOOR COVERING

BLINDS/CURTAIN RODS CEILING FLOOR VENTS

FLOOR COVERING MISC. WALL PANELS

FLOOR VENTS CEILING

WALL PANELS SECOND BEDROOM EXHAUST FAN

CEILING DOUBLE BED MISC.

MISC. BUREAU

MIRROR EXTERIOR

LIVING ROOM CLOSET FRONT DOOR

FURNITURE NIGHT STAND/BED SIDE TABLE BACK DOOR

OUTLETS LIGHT FIXTURES DOOR LOCKSETS X 2

LIGHT SWITCHES OUTLETS KEYS

LIGHT FIXTURES LIGHT SWITCHES WINDOWS

SMOKE ALARM BLINDS/CURTAIN RODS SCREENS

BLINDS/CURTAIN RODS FLOOR COVERING FRONT SIDING

FLOOR COVERING FLOOR VENTS LEFT SIDE SIDING

FLOOR VENTS WALL PANELS REAR SIDING

WALL PANELS CEILING RIGHT SIDE SIDING

CEILING MISC. GFI OUTLET

MISC. HOSE BIBB

THIRD BEDROOM ROOF SHINGLES

WATER HEATER TWIN BEDS ROOF VENTS

WATER HEATER BUREAU ROOF EDGE

WATER HEATER DOOR MIRROR TOWING HITCH

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CLOSET TOUNGE JACK

ELECTRIC NIGHT STAND/BED SIDE TABLE AXLES & SPRINGS

ELECTRIC PANNEL LIGHT FIXTURES BRAKE AXLE

OUTLETS WHEELS & TIRES

TOTAL ESTIMATED COST LIGHT SWITCHES FRAME

BLINDS/CURTAIN RODS SEWER CONNECTION

FLOOR COVERING WATER CONNECTION

FLOOR VENTS UNDERBELLY TORN

WALL PANELS TRIM DOOR

CEILING MISC.

MISC.

Additional Comments

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Attachment 1102, Staging Operation Report [C]

Staging Operations Report

FEMA Declared

Disaster #

UNIT

IDENTIFICATION STAGING OPERATIONS DETAILS

Unit Type

Bar Code

Serial

# FEMA #

Date Received at Staging

Area

Fully Mission Capable

Red/Green /Yellow

Date Converted to Fully Mission Capable

Actions Taken to Ensure Mission Capable Status

Date Dispatched

Deactivation Removal Date

Date Received After

Deactivation Condition of

Total Received Total Dispatched Total Deactivated

Totals 0 0 0

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Site Inspection Reports (SIRs) Attachments -1200

Attachment 1201, Site Feasibility Inspection Status Report [C]

SITE FEASIBILITY INSPECTION STATUS REPORT

STATUS WO#

SITE INSPECTION

ADDRESS

PRIVATE

/ COMM /

GROUP

LOT CITY COUNTY/PARISH

APPLICANT

LAST NAME

APPLICANT

FIRST NAME

SIR

ISSUE

DATE

SIR

RETURN

DATE

SIR

DETERMINATION

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Attachment 1202, Site Feasibility Inspection Report [C]

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Attachment 1203, Commercial/Group Site Feasibility Report [C]

Commercial/Group Site Feasibility Report Instructions: Complete the following site inspection report for every Work Order issued by FEMA. The site inspection report and associated documents, such as diagrams, maps, Right Of Entry (ROE) forms and photographs must be provided to the COR as defined in the contract.

Existing Commercial Park Potential Group Site

Date: _______________ Time: ______________ Inspector Name: _____________________________

Site Control Number: ______________________ Work Order Number: _________________________

Owner(s): __________________________________________ Phone: __________________________

Address: ____________________________________________________________________________

Site Latitude: _____________________________ Site Longitude: ______________________________

Acres: ___________________________________ Pads: ______________________________________

Property Availability: _____________________________________________________________

Road Access: ___________________________________________________________________

Fill Concerns: ___________________________________________________________________

Notes:_______________________________________________________________________________

UTILITIES (Y/N)

Electric Water

Gas Sewer

Phones

OTHER (Y/N)

Wetlands?

Access Bridge?

MEASUREMENTS

Miles to Nearest Elementary School

Miles to Nearest High School Miles to Nearest Hospital Distance to Nearest Fire Hydrant

Distance to Nearest Water Line Distance to Nearest Sewer Line

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Sketch:

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Attachment 1204, Right of Entry [GFI] [C]

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Attachment 1205, SIR Quality Assurance Plan (QASP) [C]

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Haul & Install Attachments – 1300

Attachment 1301, Installation Status Report [C]

Installation Status Report

STATUS WO#

INSTALL

ADDRESS

PRIVATE

/ COMM /

GROUP

LOT CITY

COUNTY

/PARISH

APPLICANT

LAST NAME

APPLICANT

FIRST NAME

W/O

ISSUED

DATE

RFO

DATE

BLDG

PERMIT

DATE

PERMIT

UNIT

TYPE

Serial #

BAR

CODE

FEMA

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Attachment 1302, RFO Checklist – Manufactured Homes [C]

FEMA RFO CHECKLIST - Manufactured Homes

CONTRATOR NAME: TASK ORDER NUMBER: TYPE OF TTHU: DATE OF

INSPECTION:

CONTRACTOR REP NAME: FEMA MONITOR NAME:

DISASTER#: TTHU BARCODE: TTHU SERIAL #: FEMA #: CONTRACTOR REP INITIALS: FEMA MONITOR INITIALS:

WORK ORDER #: PHONE NUMBER: PHONE NUMBER:

EXTERIOR

ITEM DESCRIPTION

Status: Yes/No/Not

Applicable (N/A)/Unknown

Category Description

CONTRACTOR

CERTIFICATION

INITIALS

FEMA MONITOR

INITIALS

INSTALLATION

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INSTALLTION

CHECKLIST

Is the MHU installed per the requirements on the Installation Checklist? If no, see attached Installation Checklist.

MHU LEVEL

Is the MHU Level, per the requirements in 24 CFR 3285.6?

UTILITIES

WATER PIPE LEAKS Are there any visible leaks with the waterline

WATER PIPE HEAT

TAPE

Does the water line have heat tape? Is the heat tape plugged in when appropriate?

WATER LINE PAINT Is the above ground water line painted orange?

SEWER LINE Are there any visible leaks with the sewer line?

SEWER LINE PAINT Is the above ground sewer line painted orange?

ELECTRIC METER Is the electric meter missing

ELECTRIC

If applicable, are the pre RFO testing generators still connected

ENTRY

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FRONT ENTRY

Are the steps, platform steps, or ramp properly installed and safe to use?

FRONT ENTRY LIGHT Does the front entry light work?

REAR ENTRY

Are the steps, platform steps, or ramp properly installed and safe to use?

REAR ENTRY LIGHT Does the rear entry light

TPS CLOSET DOOR

Does the TPS closet door work? Do the locks on the TPS door work?

DOOR / LOCKS Are the exterior doors and locks functioning properly?

Exterior Structure

WINDOWS Are all windows present and unbroken?

ROOF/SHINGLES

Is the roof/shingles in good condition with no broken or missing shingles?

SIDING

Is the siding in good condition with no missing or damages siding? Is all siding secured with corner trim in place?

Exterior Misc.

HOSE BIBB Are all hose bibbs functioning properly

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OUTLET(S) Are all outlets functioning

GFCI Are GFCI outlets functioning

DRYER VENT COVER Is the dryer vent cover installed?

INTERIOR

Status: Yes/No/Not

Applicable (N/A)/Unknown

Category Description

CONTRACTOR

CERTIFICATION

INITIALS

FEMA MONITOR

INITIALS

KITCHEN

FLOOR

Is the floor in good condition and free of any rips or damages.

WALLS Are the walls in good condition

CEILING Is the ceiling in good condition

LIGHTING

Are all lighting components functioning properly with LED bulbs and is the lighting globe

OUTLETS Are all outlets functioning

CABINETS Are all cabinets in good condition

OPERATING

MANUALS

Are the operating manuals present in the kitchen?

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MAINTENANCE

CONTACT INFO

Is the maintenance contact information present either on the refrigerator or table?

HOUSE KEYS

Are the entry door keys (front and back) visibly present on the kitchen counter or in the sink?

Ensure that the water heater/TPS closet key is not present.

SINK

Is the sink functioning properly with no leaks and adequate water pressure for hot and cold

EXTINGUISHER

Is the fire extinguisher present and does the gage show it is in the green area

KITCHEN

FURNISHINGS

Are all the kitchen furnishings assembled and in good

KITCHEN BLINDS Are all kitchen blinds present and in good condition

LIVING KIT Is the general living kit in the kitchen area?

CLEAN AND READY

FOR USE

Is the kitchen clean and ready for use

KITCHEN APPLIANCES

STOVE

Is the stove present? Does the oven and all range burners function properly?

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REFRIGERATOR

Is the Refrigerator and freezer functioning properly?

Does the refrigerator light

MICROWAVE

Is the Microwave present and plugged in? Do not turn on an empty microwave.

RANGE HOOD

Is the Range Hood functioning properly (vent and light)

MECHANICAL

HVAC

Is the HVAC functioning properly in both heat and cooling modes? (minimum of 5 and no more than 10 minutes in each mode is required)

WATER HEATER Is it filled with water (before turning on electricity)?

WATER HEATER Is the water heater functioning properly

ELECTRIC PANEL

Does a visual inspection of the electric panel show any issues? (microbial growth or water damage)

DEHUMIDIFIER

If applicable, is the dehumidifier present and turned on?

LIVING ROOM

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FLOOR

Is the floor in good condition damages?

CEILING Is the ceiling in good condition

LIGHTING

Are all lighting components functioning properly with LED

LIVINGROOM

FURNISHINGS

Are all the living room furnishings assembled and in good condition

WINDOWS

Do the windows open and close easily? Is there a screen installed in the window?

BLINDS

Are all blinds present, operating, and in good condition?

CO ALARM(S) /

STROBE(S)

Are the Carbon Monoxide Alarms present and working?

(when required by local authorities)

SMOKE / STROBES

Are the Smoke Detectors present and working (verified by testing)

CLEAN AND READY

FOR USE Is the living room clean

BATHROOM 1

J-56

Is the floor in good condition

CEILING Is the ceiling in good condition

VENT FAN Is vent fan functioning properly

DOOR

Is the door in good condition, functioning properly, and locking?

LIGHTING

Are all lighting components functioning properly with LED

MEDICINE

CABINET/MIRROR

Is the medicine cabinet properly attached and functional

FIXTURES

Are all fixtures present and functioning properly? Check hot and cold water in the sink, tub and shower; check that the toilet flushes. Verify all fixtures.

BATHROOM

ACCESSORIES

Are the towel bars (2-count), toilet tissue holder, shower curtain (installed), and grab bars present?

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FOR USE Is the bathroom clean

BATHROOM 2

FLOOR

Is the floor in good condition

CEILING Is the ceiling in good condition

VENT FAN Is vent fan functioning properly

DOOR

Is the door in good condition, functioning properly, and locking?

functioning properly with LED

MEDICINE

CABINET/MIRROR

Is the medicine cabinet properly attached and functional functioning properly? Check hot and cold water in the sink, tub and shower; check that the toilet flushes. Verify all fixtures.

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ACCESSORIES

Are the towel bars (2-count), toilet tissue holder, shower curtain (installed), and grab bars present?

FOR USE Is the bathroom clean

BEDROOM 1

FLOOR

Is the floor in good condition

CEILING Is the ceiling in good condition

DOORS

Are all doors in good condition? Do all doors shut and latch? (Entry and closet)

CLOSET

Is a closet hanger bar or closet hanger bar shelf combination installed?

functioning properly with LED

FURNITURE LAYOUT

Is furniture installed per the installed furniture layout?

(furniture layout is found on the interior of water heater compartment door)

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BED

Is the bed assembled with a new full sized mattress (75"x54")?

NIGHSTAND Is the nightstand present?

DRESSER

Is the dresser present and do all drawers open and close easily?

NOAA WEATHER

RADIO

Is the NOAA Weather Radio with strobe light present? Is the NOAA Weather Radio bed shaker present, if required?

operating and in good

Are the Carbon Monoxide Alarms present and working?

LIVING KIT Is the full size mattress living kit present and unopened?

FOR USE Is the bedroom clean

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BEDROOM 2

FLOOR

Is the floor in good condition

CEILING Is the ceiling in good condition

DOORS

Are all doors in good functioning properly with LED

FURNITURE LAYOUT

Is furniture installed per the installed furniture layout?

(furniture layout is found on

Is the bed assembled with a

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Is the dresser present and do

Is the NOAA Weather Radio with strobe light present? Is the NOAA Weather Radio required?

Are the Carbon Monoxide Alarms present and working?

BEDROOM 3

FLOOR

Is the floor in good condition

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CEILING Is the ceiling in good condition

DOORS

Are all doors in good functioning properly with LED

FURNITURE LAYOUT

Is furniture installed per the installed furniture layout?

(furniture layout is found on

Is the bed assembled with a

Is the dresser present and do

Is the NOAA Weather Radio with strobe light present? Is the NOAA Weather Radio

J-63 required?

BLINDS

Are all blinds present, Are the Carbon Monoxide Alarms present and working?

HALLWAY (MHU)

FLOOR

Is the floor in good condition

LIGHTING Are all lighting components

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STROBE(S)

Are the Carbon Monoxide Alarms present and working?

FOR USE Is the hallway clean

COMMENTS:

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Category Used For Definitions or Instructions

Percent Damaged Use this category for walls, floors, ceiling, roof, and siding

Percent of damage to a specific aspect of the TTHU in relation to the total amount of that aspect within a particular area (Ex. 25% of the floor is damaged in the bathroom). Use this category for walls, floors, ceiling, roof, and siding. Minor Damage: 0-20% Moderate Damage: 20-40% Considerable Damage:

40-60%, Severe Damage: 60-80%, Damaged Beyond Repair: 80-100%

Damaged Use this category for all items not listed in "Percent Damaged"

The number of damaged/missing components of a specific object that reoccurs within a particular area of the MHU TTHU (Ex. 1 out of 3 outlets are not-functional, use 1) If a furnishing or fixture is damaged/missing, make sure to mention which specific object is damaged or missing.

Not Functional Use this category for all items not listed in "Percent Damaged"

The item is not functioning properly. Just type Not Functional in the "category" column. Use this category for any object excluding those stated above in the "Percent Damaged". More than one referenced item is not functioning properly

Missing Use this category for all items not listed in "Percent Damaged"

Use this category if the object is missing. Just select Missing in the "category" column. Use this category for any object excluding those stated above in the "Percent Damaged" and "Not Functional" categories.

Status Definitions

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Unknown

The item is present, however, the inspector could not visually verify. e.g. Buried waterline is present because the water works inside the unit but, inspector cannot verify proper installation.

Yes Yes, the item is present and has been inspected.

No No, the item is not present and was not inspected.

Not Applicable (N/A) The item is not and should not be present in the unit. e.g. TPS in a travel trailer or third bedroom in a one or two bedroom unit.

NOTE: No category needed for "Blocking", "Level", or "Tie Downs/Anchoring".

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Attachment 1303, RFO Checklist – Travel Trailers [C]

FEMA RFO CHECKLIST - Travel Trailers

CONTRATOR NAME: TASK ORDER NUMBER: TYPE OF TTHU: DATE OF

INSPECTION:

CONTRACTOR REP NAME: FEMA MONITOR NAME:

DISASTER#: TTHU BARCODE: TTHU SERIAL #: CONTRACTOR REP INITIALS: FEMA MONITOR INITIALS:

WORK ORDER #: PHONE NUMBER: PHONE NUMBER:

Note: Descriptions in this document are for reference only. The requirements are found in the contract. Descriptions in this document do not supersede any of the requirements in the contract.

EXTERIOR

ITEM DESCRIPTION

Status:

Yes/No/Not Applicable

(N/A)/Unknown

Category Description

CONTRACTOR

CERTIFICATION

INITIALS

FEMA

MONITOR

INITIALS

PLACEMENT/INSTALLATION

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PLACEMENT

Is the unit placed with proper clearance from road and Disaster Dwelling

TONGUE STRAP

Is there a strap on the tongue and is it properly tightened

LEVELING JACKS (LOWERED)

Are the Leveling Jacks lowered, not exceeding 75%

LEVELING JACK PIER

If required, is the pier properly constructed?

LEVELING JACKS (ABS PADS OR

WOOD)

Are the ABS pads or wood present under Jacks? If ABS pads are used, is the smooth side up?

(Not required when TT is placed on a preexisting concrete pad that is in good shape)

TIRE PROTECTION

Are the tires protected from direct contact with the ground.

ABS Pads or wood underneath tires, set, level & flush with the ground

TIRE CHOCKS

Are the tires chocked to prevent tire movement. Approve methods include wood, rubber, or urethane chocks or other types of wheel immobilizers for travel trailers

BUMPER STRAPS

Are there two Straps on rear bumper and is it properly tightened

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ANCHORS/STRAPS

Is each anchor installed per the manufacturer's instructions? Is the head of each anchor parallel and flush to the ground? Is each strap wrapped around the Split bolts? Ensure all excess strap material is removed.

ANCHOR STRAP PAINT

Is each anchor strap painted orange

TT LEVEL Is the TT level?

TONGUE LIGHT

If applicable, does the tongue light operate?

PROPANE TANKS

Are the Propane Tanks connected and full

UTILITIES

WATER PIPE CONNECTION

Is the water piping connected and working properly

WATER PIPE LEAKS

Are there any visible leaks with the waterline

WATER PIPE INSTALLATION

Is the water line buried to proper depth or installed above ground, supported properly and marked with orange paint? Is the water line insulated properly?

WATER PIPE HEAT TAPE

Does the water line have heat tape

SEWER LINE SLOPE

Is the sewage system connected properly (check slope, has proper

J-70 fall, etc.) and in working condition

SEWER LINE INSTALLATION

Is the sewer line buried to proper depth or installed above ground, supported properly and marked with orange paint?

SEWER LINE CLEANOUT

Is the Sewer line Cleanout missing or uncapped

ELECTRIC METER Is the electric meter missing

ELECTRIC

If applicable, are the pre RFO testing generators still connected

ENTRY

PRIMARY ENTRY

Are the steps, platform steps, or ramp properly installed and safe to use?

PRIMARY ENTRY LIGHT

Does the primary entry light

SECONDARY ENTRY

(IF APPLICABLE)

Are the steps, platform steps, or ramp properly installed and safe to use?

SECONDARY ENTRY LIGHT

(IF APPLICABLE)

Does the secondary entry light

DOOR / LOCKS

Are the exterior doors and locks functioning properly?

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Exterior Structure

WINDOWS

Are all windows present and unbroken?

ROOF Is the roof in good condition?

EXTERIOR WALLS Are exterior walls damaged?

EXTERIOR STORAGE

COMPARTMENTS

Are the storage compartment(s) doors and locks functioning properly?

OUTLET(S)

Are all outlets functioning

GFCI

Are GFCI outlets functioning

INTERIOR

Status:

Yes/No/Not Applicable

(N/A)/Unknown

Category Description

CONTRACTOR

CERTIFICATION

INITIALS

FEMA

MONITOR

INITIALS

KITCHEN/LIVING AREA

FLOOR

Is the floor in good condition and free of any rips or damages.

WALLS Are the walls in good condition

CEILING Is the ceiling in good condition

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Are all lighting components functioning properly (including the range hood light and fan)

OUTLETS

CABINETS Are all cabinets in good condition

SINK

Is the sink functioning properly with no leaks and adequate water pressure for hot and cold

EXTINGUISHER

Is the fire extinguisher present and does the gage show it is in the green area

CO ALARM(S) / STROBE(S)

Are the Carbon Monoxide Alarms present and working? (Strobe required in accessible TT only)

Are the Smoke Detectors present and working (verified by testing and strobe required in accessible TT only)

KITCHEN/LIVING AREA

Are all the kitchen/living area furnishings assembled and in good condition? Are there any cushions missing?

KITCHEN/LIVING AREA BLINDS

Are all kitchen/living area blinds present, operating properly and in good condition?

GENERAL LIVING KIT

Is there a general living kit in the kitchen/living area?

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OPERATING MANUALS

Are the operating manuals present in the kitchen?

MAINTENANCE CONTACT INFO

Is the maintenance contact information present either on the refrigerator or table?

HOUSE KEYS

Are the entry door and storage compartment keys visibly present on the kitchen counter or in the sink?

Do the windows open and close easily? Is there a screen installed in the window?

SKYLIGHT

If applicable, does the skylight have any visible cracks?

ROOF VENT

If applicable, does the roof vent function properly and is in good condition? Is there a screen in

CLEAN AND READY FOR USE

Is the kitchen/living area clean and ready for use

KITCHEN APPLIANCES

STOVE

Is the stove present? Does the oven and all range burners function properly?

REFRIGERATOR

Is the Refrigerator and freezer functioning properly? Does the refrigerator light work? Verify

J-74 that the refrigerator is operating on AC electric.

MICROWAVE

Is there a Microwave and if so, RANGE HOOD/ VENT FAN

Is the Vent Fan functioning properly? If there is a range hood, is it damaged?

MECHANICAL

AIR CONDITIONING

Are the air conditioning unit(s) functioning properly?

HEAT Is the heat functioning properly?

ELECTRIC PANEL

Does a visual inspection of the electric panel show any issues?

(Microbial growth or water damage)

SKYLIGHT

ROOF VENT OR VENT FAN

Does the roof vent or vent fan function properly and is in good

J-75 place?

DOOR Is the door in good condition

LIGHTING

MEDICINE CABINET/MIRROR

Is the medicine cabinet properly attached and functional functioning properly? Check hot and cold water in the sink, tub and shower; check that the toilet flushes. Verify adequate water pressure for all fixtures.

BATHROOM ACCESSORIES

Are the towel bars (2-count), toilet tissue holder, shower curtain (installed) or shower enclosure present, and grab bars present?

CLEAN AND READY FOR USE Is the bathroom clean

BEDROOM 1

FLOOR

J-76

SKYLIGHT

function properly and is in good

DOORS

Are all doors in good condition?

Do all doors shut and latch?

(Entry and closet)

Is a closet hanger bar or closet hanger bar shelf combination

Are all the furnishings in good condition? Are the Mattresses new?

Is the bed present with an appropriately sized mattress?

NIGHSTAND

If applicable, is the nightstand

Is the dresser present and do all drawers open and close easily?

NOAA WEATHER RADIO

Is the NOAA Weather Radio with strobe light present? Is the NOAA

J-77

Weather Radio bed shaker present, if required?

WINDOWS

Does the window open and is there a screen present?

Are all blinds present and in good

Are the Carbon Monoxide Alarms and working (verified by testing and strobe required in accessible TT only)

LIVING KIT

Is the appropriately size mattress living kit present and unopened?

CLEAN AND READY FOR USE Is the bedroom clean

BEDROOM 2

FLOOR

SKYLIGHT

function properly and is in good

J-78 place?

DOORS

Are all doors in good condition?

Do all doors shut and latch?

(Entry and closet)

Is a closet hanger bar or closet hanger bar shelf combination

Are all the furnishings in good condition? Are the Mattresses new?

Are the beds present with the appropriately sized mattresses?

NIGHSTAND

If applicable, is the nightstand

Is the dresser present and do all drawers open and close easily?

Does the window open and is there a screen present?

Are all blinds present and in good

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Are the Carbon Monoxide Alarms and working (verified by testing and strobe required in accessible TT only)

LIVING KIT

Is the appropriately size mattress living kit present and unopened?

CLEAN AND READY FOR USE Is the bedroom clean

COMMENTS:

J-80

Category Used For Definitions or Instructions

Percent Damaged Use this category for walls, floors, ceiling, roof, and siding

Percent of damage to a specific aspect of the TTHU in relation to the total amount of that aspect within a particular area (Ex. 25% of the floor is damaged in the bathroom). Use this category for walls, floors, ceiling, roof, and siding. Minor Damage: 0-20% Moderate Damage: 20-40% Considerable Damage:

40-60%, Severe Damage: 60-80%, Damaged Beyond Repair: 80-100%

Damaged Use this category for all items not listed in "Percent Damaged"

The number of damaged/missing components of a specific object that reoccurs within a particular area of the TTHU (Ex. 1 out of 3 outlets are not-functional, use 1) If a furnishing or fixture is damaged/missing, make sure to mention which specific object is damaged or missing.

Not Functional Use this category for all items not listed in "Percent Damaged"

The item is not functioning properly. Just type Not Functional in the "category" column. Use this category for any object excluding those stated above in the "Percent Damaged". More than one referenced item is not functioning properly

J-81

Missing Use this category for all items not listed in "Percent Damaged"

Use this category if the object is missing. Just select Missing in the "category" column. Use this category for any object excluding those stated above in the "Percent Damaged" and "Not Functional" categories.

Status Definitions

Unknown

The item is present, however, the inspector could not visually verify. e.g. Buried waterline is present because the water works inside the unit but, inspector cannot verify proper installation.

Yes Yes, the item is present and has been inspected.

No No, the item is not present and was not inspected.

Not Applicable (N/A) The item is not and should not be present in the unit. e.g. TPS in a travel trailer or third bedroom in a one or two bedroom unit.

NOTE: No category needed for "Blocking", "Level", or "Tie Downs/Anchoring".

J-82

Attachment 1304, Release of Installation Material [C]

PRIVATE LANDOWNER’S RELEASE AND ACCEPTANCE OF PERSONAL PROPERTY

(Material used to crown under the housing unit)

I, __________________________________________________ (print clearly), the undersigned, owning the property located at:

____________________________________________________________________ (print clearly street address) in

___________________________________________________ (print clearly City, County, State and Zip Code) state as follows: I am a private property owner. The Federal Emergency Management Agency (FEMA) and/or its agents have installed a temporary transportable housing unit (“TTHU”) on my property in response to my request for disaster assistance under the Individuals and Households Program (Section

408) of the Robert T. Stafford Act, Pub. L. 93-288, 42 U.S.C. § 5174, as amended; 44 C.F.R. § 206.110 – 118; and related authorities. I certify that I am the owner of the property on which the TTHU is installed.

As part of the TTHU installation, FEMA provided material (the “Material”) to crown the area under the housing unit to insure proper drainage. The aforementioned Material can include, but is not limited to, ground cover cloth and stone, or other material used to create the crown. I have requested that during the removal of the TTHU that FEMA, and/or its agents, do not remove the Material. I am aware that FEMA has agreed to abandon the Material in response to my request and I understand that FEMA, and/or its agents, shall leave the Material in place and is not responsible for any movement or transportation of the Material. The Material has no monetary value and no compensation is due to FEMA.

I release FEMA and/or its agents from any responsibility for the removal of the Material. The Material shall become my personal property. I also waive, release, and discharge the United States and/or its agents from any and all liability, arising from or incident to the abandonment of the Material, use prior to or after the abandonment, or its final disposition; and to hold the United States, and/or its agents, harmless from and shall indemnify the United States, and/or its agents, against any or all debts, liabilities, judgments, costs, demands, suits, actions, or claims of any nature arising from or incident to the abandonment of the Material, its use prior to or after the abandonment, or its final disposition.

Dated this __________ day of _______________________, 20_________.

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PRIVATE LANDOWNER’s signature

Witness Name (Printed clearly)

Witness signature

J-84

Attachment 1305, Installation Appendix [C]

J-85

Attachment 1306, FEMA TTHU Transfer Inspection Form [C]

FEMA TTHU Transfer Inspection Form

1. Temporary Housing Unit No.

2. Serial No./Vin

3. TYPE OF INSPECTION 4. TYPE OF UNIT 5. UNIT INFORMATION

Transport Dispatch Receipt

Storage

Staging

Install Delivery

Deactivation

New Unit Inspection

Other

Manufactured Home

Travel Trailer

a. Manufacturer

b. Year

c. Size

d. Number of Bedrooms

CONDITION OF FURNISHINGS, INTERIOR &

EXTERIOR

N = New G = Good D = Damaged M = Missing

OFF THE LOT

YES NO

Furnishings Condition Furnishings Condition Furnishings Condition

Kitchen & Dining

First

Bedroom

Bathroom

Dinette Table Double Bed, Complete

Commode

Dinette Chairs (6 for 3 BR)

Mirror Tub/Shower

J-86

Stove Cabinets Storage

Lavatory

Range Hood & Vent

Blinds Cosmetic Cabinet

Refrigerator Light Fixtures Mirror

Blinds Second

Blinds

Cabinets Double Bed, Complete

Light Fixtures

Sink Mirror Exterior Condition

Light Fixtures Cabinet Storage

Water Heater

Fire Extinguisher Blinds Doors

A/C

Light Fixtures 2 Keys Per Door

Living Room Third

Windows

Couch Double, complete

Screens

Armchair Mirror Front Panels

End Table Cabinet Storage

Left Side Panels

Coffee Table Blinds Rear Panels

Blinds Light Fixtures Right Side Panels

Light Fixtures Interior Condition

Roof Vents

Hall Floor Covering

Towing Hitch

Furnace Wall Panels Axels & Springs

Smoke Detector Ceiling Panels Wheels & Tires

Light Fixtures TPS

J-87

9. MARK LOCATION OF EXTERIOR DAMAGE ON DIAGRAM BELOW:

RIGHT SIDE LEFT SIDE

ROOF

FRONT REAR

UNDERBELLY

10. COMMENTS (if more space is needed, continue on reverse)

NOTE: Tail light harness furnished by: Towing Contractor

J-88

11. REPRESENTATIVES ACKNOWLEDGED BY:

NAME (Inspector) SIGNATURE AND DATE (Dispatch Inspector) SIGNATURE AND DATE (Receiving Inspector)

Dispatch To/From

Receipt To/From

Dispatch To/From Site

HSFE80-17-R- 0005 Section J

AUGUST 18, 2017

J-89

Attachment 1307 – Individual Installation Report [C]

US DEPARTMENT OF HOMELAND SECURITY

FEDERAL EMERGENCY MANAGEMENT AGENCY

Direct Housing Unit Installation Work Order

1. Site Control # 2. Contractor 3. Work Order #

WORKORDER STATUS: AS OF:

4. Pickup Location Delivery Location

Name

Phone No. Name

Phone No.

Lot# Address

Lot #

City, State

County City, State

County

5. Work Order Information Issued to Issue Date Issue Time Issued By Date Completed

6. Site Type: Commercial Private Community EGS Directions

7. Unit Information 8. Pad Lot Information Unit Type. Barcode Pad Lot # Pad Type

Make VIN

Pad Size Rent Amt.

Model Furnished? Amps Split Lot?

Year # Bedrooms Utilities

9. Work Order Specifications

Description/Line Item Number UOM Quantity Cost Per UOM Total

TOTAL

10. Work Order Notes - Plot Information (attach an additional sheet)

11. Install Information Setup Date Made Ready Date Inspection Date Inspection Status RFO Date RFO Package Sent

12. Verification and Signatures: The above described work has been verified by:

Install Contractor

COR Project Officer

Site Inspector / Tech Monitor

Section J

FEMA Form 90-26

GENERAL INFORMATION

Purpose. The TTHU Installation Work Order is used to issue and track individual work orders against a contract for installing (site development and set-

up) TTHUs. It identified the work completed and serves as an acceptance document for all work completed.

Responsibility. DHOPS initiates word orders when the site is determined feasible for a unit by completing items 1,4,6,7 and 9. The Project Officer completed items 3 and 5 to issue the work order and item 7 when determined. The Installation Inspector completes the quantities in item 9 and signs item 11 Site Inspector/Technical Monitor (SI/TM) when work has been completed. Item 11 self-explanatory

DISTRIBUTION LIST: Upon Issuance to the Contractor:

Original and 1 Copy - Retained by DHOPS Copy No 3 - Contractor, for authorization to work Copy No 4 - Staging Contractor delivers as authority to dispatch unit Copy No 5 - Inspector Copy - Computer Entry

Upon Completion of the Mobile Home Installation and All Items on the Form:

Original and Copy No 1 Retained by DHOPS Copy No 2 - Contractor Copy - Computer Entry

Upon Receipt of the invoice and verification of cost: Original - Fiscal Copy No 1 - DHOPS Contractor File

INSTRUCTIONS

1. Self-Explanatory.

2. Work Order Number. Consists of the contract number assigned by the Office of Acquisition Management, plus a sequential number for each work order issued. (Example EMX-86-0301-001).

3 - 6. Self-Explanatory.

7 - 8. Self-Explanatory

9. Work Order Specifications. The Field Inspector will check place the appropriate items within the Line Item Description blocks based on the requirements. During the final inspection the inspector will complete the Quantity Column. The Project Officer will complete the Cost Per UOM and provide Line Item Numbers.

10. Plot Plan/Directions/Comments: The Field Inspector will provide all pertinent information (boundaries, utility risers, unit home perimeter, etc.)

Directions should be from the staging area to the site the TTHU will travel. The Field Inspector will draw a plot plan on a separate sheet of paper and attach.

11. The Field Inspector will check off all appropriate Accessible Items that will apply in regards to survivors receiving a UFAS housing unit.

12. Self-Explanatory

Attachment 1308 – RFO Quality Assurance Plan (QASP) [C]

Tank and Pump System (TPS) Attachments – 1400

Attachment…