H01 Technical Exhibit 12 Sample NCIR.doc

NONCONFORMANCE INSPECTION REPORT (SEE INSTRUCTIONS ON REVERSE)

PAGE____1____OF___1__PAGES

1. REPORT NUMBER

00001

Tower#1

DPW, Housing Div

10. DESCRIPTION OF NONCONFORMANCE CONDITION(S) OR ITEM(S)

(Reference the specifications, page, para, drawing number, as applicable)

14. CONTRACTOR CORRECTIVE ACTION

(Identify date/time of completion; initial each item)

This nonconformance report is issued to you on ________13 Sep 19_________. Contractor to repair

Non-conformance items identified in “10”. Return this form to Family Housing, Facilities Management

15. CONTRACTOR REPRESENTATIVE (QC) SIGN AND DATE

Branch, DPW Housing, Building 309.

20. COR COMMENTS

12. INSPECTED BY

17. REVIEWED BY

INSTRUCTIONS FOR COMPLETING NONCONFORMANCE INSPECTION REPORT

INSPECTOR’S INSTRUCTIONS (when issuing Nonconformance Report to contractor).

BLOCK 1-9

Fill out all information in these blocks. Mark N/A in blocks which do not apply.

BLOCK 10

Identify and list all nonconformance conditions of inspection. If additional sheets are needed use another Nonconformance Inspection Report and identify as next page. Reference the paragraph (para), page, and drawing number to the nonconformance condition, if applicable. Record any additional remarks pertinent to your inspection.

BLOCK 11

Fill in the date and time you issued the Nonconformance Report to the contractor. Indicate the date and time the contractor has to repair the nonconformance conditions and to return the report to the Housing, Facilities Management Branch. Reference the contact specifications page and paragraph number as it applies to time limit for repairing and/or re-performing service.

BLOCK 12

Sign and date the report.

BLOCK 13

Identify the type of inspection (i.e., Final, Re-Inspection, Change of Occupancy Cleaning (COC), Flooring, Change of Occupancy Painting (COP) etc.

CONTRACTOR’S INSTRUCTIONS (when correcting nonconformance items).

BLOCK 14

Correct nonconformance items. Indicate the date and time that each item/condition listed in Block 10 was corrected. Remark on any condition related to the repair such as extenuating circumstances which may prevent you from performing the corrective action.

BLOCK 15

Contractor Q.C. representative sign and date after the repairs are made. Return the completed report to the Housing, Facilities Management Branch, within the time frame identified in the referenced contract specifications. The Housing, Facilities Management Branch is located at USAG Humphreys, Building 309, telephone (DSN) 753-5798.

INSPECTOR’S INSTRUCTIONS (when receiving Nonconformance Report from contractor).

BLOCK 16

Identify the date and time the contractor returned the form or when the form was received at DPW Housing, Facilities Management Branch.

BLOCK 17

This block is for supervisory review after the form is returned from contractor.

INSPECTOR’S INSTRUCTIONS

BLOCK 18

Perform follow up inspection on rejected items. Indicate date and time of re-inspection (if applicable). Comment on any circumstances. If no follow up inspection is made, indicate not re-inspected.

BLOCK 19

Sign and date. Forward to the COR.

COR’S INSTRUCTIONS

BLOCK 20

Review this report. Add or attach comments. Coordinate input with Contracting Office if required.

BLOCK 21

Sign and date the report. Forward this copy to 411th, CSB, Humphrey’s office, Contract Administrator if required.

Retain this copy in the COR, Facilities Management Branch files.

PAGE