S02 - Attachment D - Sample Survellience Checklist.docx

This is a Surveillance Checklist template for monitoring contractor performance on a ground ambulance service contract. The checklist is designed for use by Government Points of Contact to conduct inspections at contractor facilities and document compliance with contract requirements outlined in the Performance Work Statement (PWS).

The checklist establishes six key performance standards (SS1-SS6) with corresponding surveillance methods and compliance thresholds. The primary standard requires 24/7/365 ambulance service availability with 95% compliance monitored through 100% surveillance of each patient pick-up. Additional standards address vehicle maintenance (95% compliance), maintenance documentation procedures (95% compliance), qualified personnel requirements (100% compliance), personnel training per Department of Health and Human Services standards with a minimum 150-hour curriculum (100% compliance), and sanitation procedures meeting Occupational Safety and Health Administration bloodborne pathogen protocols under supervision of a licensed Medical Transportation Officer (100% compliance). The checklist includes columns for documenting whether each performance objective is met or not met, along with remarks sections for inspector notes. This template applies to the non-emergent ground ambulance ordering period contract (36C25226Q0304) for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 12, covering the period April 1, 2026 through March 31, 2031.