S02 - Attachment 2 Sample Quality Assurance Monitoring Form.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C25221R0084
About this file
This document contains a sample quality assurance monitoring form and details of a federal contract opportunity for special mode transportation services. The Department of Veterans Affairs, Great Lakes Acquisition Center intends to issue solicitation 36C25221R0084 for wheelchair van and sedan transportation services for beneficiaries of the Jesse Brown VA Medical Center, requiring transports throughout Illinois and Indiana. The contractor shall provide 24/7 transportation services for one base year plus four option years. The NAICS code is 485991 and it is being set aside as a tiered small business evaluation for SDVOSB, VOSB, small business with priority for HUBZone and 8(a) participants, and then large businesses. The contract will be firm fixed price.
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Text version
ATTACHMENT 2: SAMPLE QUALITY ASSURANCE
MONITORING FORM
SERVICE or STANDARD:
SURVEY PERIOD:
SURVEILLANCE METHOD (Check):
Random Sampling 100% Inspection Customer Complaint LEVEL OF SURVEILLANCE (Check):
| 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): | Exceeds Standards |
| Meets Standards | |
| Partially Meets Standards | |
| Does Not Meet Standards | |
| Pass | |
| Fail |
Narrative of Performance During Survey Period:
PREPARED BY: ___________________________________ DATE: _________________
SIGNATURE:
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