CFO Audit Support QASP.docx

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Chief Financial Officers Audit
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W56ZTN24R0009
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This document is a Quality Assurance Surveillance Plan (QASP) for a federal contract opportunity entitled "Chief Financial Officers Audit (CFOA) Audit Readiness Support". The QASP outlines the procedures and guidelines the U.S. Army Garrison, Aberdeen Proving Ground, Directorate of Public Works will use to monitor the contractor's performance and ensure the required performance standards or service levels are met.

The key details include:

  • The contract will provide real property, real estate, audit readiness, and Chief Financial Officer's Audit support services at Aberdeen Proving Ground, Adelphi Laboratory Center, and Blossom Point Research Facility.
  • The performance management approach is results-focused, allowing the contractor flexibility in how the work is performed as long as the critical outcomes are achieved.
  • The QASP defines the roles and responsibilities, performance standards, monitoring methods, quality assurance documentation, and performance analysis and reporting processes.
  • The acceptable quality levels for the various required services range from 95-100% compliance.
  • Contractor performance will be monitored through random sampling, periodic inspections, and customer feedback, with remedies for non-conforming services.

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Technical Exhibit CFO Audit Readiness.docx DOCX document
CFOA Audit Readiness Support PWS.docx DOCX document

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QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Aberdeen Proving Ground (APG) & Adelphi Laboratory Center (ALC) and Blossom Point Research Facility (BPRF)

APG-ALC-BPRF Chief Financial Officers Audit (CFOA) Audit Readiness Support

01 February 2023 i

TABLE OF CONTENTS

1INTRODUCTION1
1.1Purpose1
1.2Performance Management Approach1
1.3Performance Management Strategy2
2ROLES AND RESPONSIBILITIES2
2.1The Contracting Officer2
2.2The Contracting Officer’s Representative2
3IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS2
4METHODOLOGIES TO MONITOR PERFORMANCE3
4.1Surveillance Techniques3
4.2Customer Feedback3
4.3Acceptable Quality Levels3
5QUALITY ASSURANCE DOCUMENTATION4
5.1The Performance Management Feedback Loop4
5.2Monitoring Forms4
6ANALYSIS OF QUALITY ASSURANCE ASSESSMENT4
6.1Determining Performance4
6.2Reporting4
6.3Reviews and Resolution4
ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY6
ATTACHMENT 2: QUALITY ASSURANCE MONITORING FORM15
ATTACHMENT 3: QUALITY ASSURANCE MONITORING FORM – CUSTOMER COMPLAINT INVESTIGATION16

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled “CFOA Audit Readiness Support”. This plan sets forth the procedures and guidelines the US Army Garrison, Aberdeen Proving Ground, Directorate of Public Works will use in ensuring the required performance standards or services levels are achieved by the contractor.

Purpose The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

Performance Management Approach The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the US Army Garrison, Aberdeen Proving Ground, and Directorate of Public Works to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

Performance Management Strategy The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

1.3.2 The Contracting Officer’s Representative (COR) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

ROLES AND RESPONSIBILITIES

The Contracting Officer The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the contracting officer's representative (COR) and the contractor. The CO will designate a COR as the government authority for performance management.

The Contracting Officer’s Representative The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.”

METHODOLOGIES TO MONITOR PERFORMANCE

Surveillance Techniques In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are

· Random monitoring, which shall be performed by the COR.

· Periodic Inspection – COR typically performs the periodic inspection monthly.

· Customer Feedback – COR will review completed work and contact users to determine if the quality and timeliness of finished work met customer expectations and contract requirements.

Customer Feedback The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems, but the customer always has the option to communicate complaints to the COR as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer Complaint Investigation, identified in Attachment 3.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

Acceptable Quality Levels The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed. Levels of performance are keyed to the relative importance of the task to the overall mission performance at the US Army Garrison, Aberdeen Proving Ground, Directorate of Public Works.

QUALITY ASSURANCE DOCUMENTATION

The Performance Management Feedback Loop The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques shown in Attachment 1.

Monitoring Forms The government’s QA surveillance, accomplished by the COR, will be reported using the monitoring forms in Attachments 2 and 3. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

The COR will retain a copy of all completed QA surveillance forms.

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

Reporting At the end of each month, the COR will prepare a written report summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

Reviews and Resolution The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO and other government IPT personnel as deemed necessary to discuss performance evaluation. The CO will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR as often as required or per the contractor’s request. The agenda of the reviews may include:

· Monthly performance assessment data and trend analysis

· Issues and concerns of both parties

· Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

· Recommendations for improved efficiency and/or effectiveness

The QAR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services

Performance Standard
Acceptable Quality Level (AQL)
Method of Surveillance
Incentive (Positive and/or Negative)

# 1.

The Contractor shall provide all personnel and supervision necessary and perform Real Property (GFEBS/ePRISMS), Real Estate (Audit Readiness/Chief Financial Officer’s Audit) support services IAW TE 2.

The Contractor shall provide services IAW PWS, para. 1.2.
2% Deviation from performance Standard.

% Calculated by dividing the number of defects by the number of observations.

Random Sampling and Customer Complaints; Inspections and complaint validations performed by the COR/ACOR.
Contractor compliance rate shall be utilized as objective evidence of contract compliance and documented into the CPAR System; Contractor shall re-perform the service.

# 2.

The Program Manager shall be available after normal duty hours to serve as the central point of contact for Contractor operations.

The Contractor shall provide a central point of contact IAW PWS, para. 2.1.4.1.
Zero Deviation from performance standard
100% daily and verification/confirmation by the COR/ACOR.
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

#3.

The Contractor shall develop and maintain a Quality Control Plan approved by the KO.

The Contractor shall provide a QCP IAW PWS, para, 4.2.
Zero Deviation from performance standard.
Review and acceptance by the by the KO on submission of QCP and each revised QCP.
Non-conforming services will result in Non-Conforming Reports issued and a potential negative CPARS narrative.

# 4.

The Contractor shall remove, from the job site, any employee for reasons of misconduct or security.

Employee conduct complies with 41 U.S.C. 423, Procurement Integrity, IAW PWS para. 2.1.11.1.6.

Zero Deviation from performance standard.

The COR/ACOR will review 100% of Contractor reported occurrences of Contractor employee misconduct, including but not limited to violations of any provision indicated at 41 U.S.C. 423, and/or security violation to ensure the offending employee is removed from the job site.
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential equitable adjustment by the Contracting Officer.

#5.

Damages caused by Contractor employees shall be repaired at no cost to the Government.

The Contractor shall notify the COR/ACOR and return the damaged area to its previous condition AW PWS, para. 3.1.1.1.
Zero Deviation from performance standard
COR/ACOR will review 100% of damage reports.
Non-conforming services will result in Non-Conforming Reports issued and a potential negative CPARS narrative.

#6.

The Contractor will ensure that the licenses or certificates and training of Contractor personnel are kept current. Copies of these licenses or certifications will be provided to the COR/ACOR.

The Contractor shall perform IAW PWS, para. 2.3.4.1.

Zero Deviation from performance standard (Risk assessed high risk)

100 Percent Inspection of copies of these licenses or certifications
Non-conforming services will result in Non-Conforming Reports issued and a potential negative CPARS narrative

Project Management Plan: (Para. 1.0)

Project Management Plan: Prepare PMP Plan prior to kick-off meeting (TE-2)
Plan
95% of PMP accepted without changes
Review and acceptance of PMP Plan
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

Real Property Support: (Para. 2.1-2.5)

Presentation and Briefing Support (TE-2)
Presentations
95% of tasks performed meet requirements
File reviews, periodic inspections, random observations, customer complaints.
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Provide Proper Accountability for Real Property Records (TE-2)
Reviews
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Provide Space Planning and Management Support. (TE-2)
Studies and Investigations
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Maintain Real Property Facility Project Files (TE-2)
FIF Folder Updates
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Prepare Disposal Documents (TE-2)
Documents
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Support Facility Reduction Program (TE-2)
Prepare Disposal Documents
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Provide Database Management and Maintenance through GFEBS (TE-2)
GFEBS Updates
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Provide Real Property GIS Support (TE-2)
GIS Maps
95% of tasks performed meet requirements
File reviews, periodic inspections, and random, observations, customer complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

Audit Readiness and Compliance Support: (Para. 2.6)

Examined Asset Record (TE-2)
Reviews
95% of tasks performed meet requirements
Inspection for contractor corrective actions.
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Submittal Package (TE-2)
Asset Submittal Package
95% of tasks performed meet requirements
Periodic Inspection
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Property Inventory Minimum Data Worksheet (PIMD) (TE-2)
Completed PIMD Worksheets
95% of tasks performed meet requirements
Periodic Inspection, File Review
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
GFEBS Updates (TE-2)
GFEBS Updates
95% of tasks performed meet requirements
Periodic Inspection
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Facility Individual Folders (TE-2)
FIF Folder Updates
95% of tasks performed meet requirements
Periodic Inspection, File Review
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Memorandum for Records for Alternative Valuation and creation of missing documents (TE-2)
Prepared MR's
95% of tasks performed meet requirements
Periodic Inspection, File Review
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Monthly status report per PWS (TE-2)
Reports
95% of tasks performed meet requirements
File Review
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

ePRISMS Support: (Para. 3.1)

Data Collection and Development: Floor Plan Field Surveys (TE-2)
Surveys
95% of tasks performed meet requirements
Periodic inspections, and random observations, customer feedback and complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Data Collection and Development: Manpower Field Surveys (TE-2)
Surveys
95% of tasks performed meet requirements
Periodic inspections, and random observations, customer feedback and complaints
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Data Collection and Development: CADD Floor Plan Development. (TE-2)
Floor Plans
95% of tasks performed meet requirements
File reviews
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Floor Plan Upload to ePRISMS (TE-2)
Uploads to IMCOM
95% of tasks performed meet requirements
File reviews, periodic inspections, and random observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Space and Manpower Data Entry into ePRISMS (TE-2)
ePRISMS Updates
95% of tasks performed meet requirements
File reviews, periodic inspections, and random observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
GFEBS Updates (TE-2)
GFEBS Updates
95% of tasks performed meet requirements
File reviews, periodic inspections, and random observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Real Property Documentation Updates (TE-2)
Assignment, Re-assignment Letters
95% of tasks performed meet requirements
File reviews
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Real Property Reconciliation Report (TE-2)
Reports
95% of tasks performed meet requirements
File reviews
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

GIS Support: (Para. 3.2)

Create geospatial data layers.

(TE-2)

New data layers
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Raster or Vector conversions (TE-2)
Conversions
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Geospatial data layer updates (TE-2)
Updates
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
As-Builts updates (TE-2)
Updates
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Metadata updates (TE-2)
Updates
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Large format scanning (TE-2)
Scans
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Printing and plotting drawings and maps (TE-2)
Prints
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Create geospatial documents, SOPs, technical articles, and other documentation (TE-2)
New Documents
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Quarterly Meetings (TE-2)
Meetings
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

CADD Support: (Para. 4.0)

Data request (TE-2)
Request
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

Create new CAD drawings.

(TE-2)

CAD Drawings
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Update existing CAD drawing (TE-2)
Updates
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
CAD file conversion (TE-2)
Conversions
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
CAD file configuration (TE-2)
Configurations
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Document Library Updates (TE-2)
Updates
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Drawing disposal (TE-2)
Drawings Removed
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
CAD QAQC (TE-2)
Inspections
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.
Training documentation and SOPs (TE-2)
Documents
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

Monthly Status Report: (Para. 5.0)

Monthly Status Report (TE-2)
Reports
95% of tasks performed meet requirements
File reviews, periodic inspections and random, observations
Non-conforming services will result in Non-Conforming Reports issued to Contractor and potential negative CPARS report.

ATTACHMENT 2: QUALITY ASSURANCE

MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint LEVEL OF SURVEILLANCE (Check):

MonthlyQuarterlyAs needed.
PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD:______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check):Meets Standards
Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: ____________________________ DATE: _________________

ATTACHMENT 3: QUALITY ASSURANCE MONITORING FORM – CUSTOMER COMPLAINT INVESTIGATION

SERVICE PROVIDED: __________________________________________________________________________________________________________________________________________________________________________________________________________________

DATE/TIME COMPLAINT RECEIVED:_____________________ AM / PM
SOURCE OF COMPLAINT:_______________________________ (NAME)
_______________________________ (ORGANIZATION)
_______________________________ (PHONE NUMBER)
_______________________________ (EMAIL ADDRESS)

NATURE OF COMPLAINT: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ RESULTS OF COMPLAINT INVESTIGATION: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DATE/TIME SERVICE PROVIDER INFORMED OF COMPLAINT: ______________________

CORRECTIVE ACTION TAKEN BY SERVICE PROVIDER: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RECEIVED AND VALIDATED BY: _____ __

PREPARED BY: ____________________________ DATE: ____________________

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