**PLEASE SEE "HELPFUL HINTS" AT END OF DOCUMENT**

**QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)**

**Facility Operation and Maintenance Support Services**

**for the**

**USDA, Agricultural Research Service**

**Western Regional Research Center**

**Albany, California**

**TABLE OF CONTENTS**

[1.0 INTRODUCTION 1](#introduction)

[[1.1]{.smallcaps} [PURPOSE]{.smallcaps} 1](#purpose)

[[1.2]{.smallcaps} [PERFORMANCE MANAGEMENT APPROACH]{.smallcaps}
1](#performance-management-approach)

[[1.3]{.smallcaps} [PERFORMANCE MANAGEMENT STRATEGY]{.smallcaps}
2](#performance-management-strategy)

[2.0 ROLES AND RESPONSIBILITIES 2](#roles-and-responsibilities)

[3.0 IDENTIFICATION OF SERVICES TO BE PERFORMED
2](#identification-of-services-to-be-performed)

[4.0 METHODOLOGIES TO MONITOR PERFORMANCE
3](#methodologies-to-monitor-performance)

[5.0 QUALITY ASSURANCE REPORTING 3](#quality-assurance-reporting)

[6.0 ANALYSIS OF QUALITY ASSURANCE MONITORING RESULTS
4](#analysis-of-quality-assurance-monitoring-results)

[7.0. FAILURE TO PERFORM 5](#failure-to-perform)

## LIST OF ATTACHMENTS

[ATTACHMENT I Required Performance Metrics (RPM)
6](#__RefHeading___Toc70750094)

ATTACHMENT II Quality Assurance Monitoring Form 8

ATTACHMENT III Quality Assurance Monitoring Form - Customer Complaint
Investigation..........................9

**QUALITY ASSURANCE SURVEILLANCE PLAN**

**(QASP)**

# 1.0 INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) is pursuant to the
requirements listed in the performance-based Performance Work Statement
(PWS) entitled "Facilities Operations and Maintenance Support Services
for the Western Regional Research Center (WRRC)". This performance-based
plan sets forth the procedures and guidelines the Albany Research Center
will use in evaluating the technical performance of the operations and
maintenance (O&M) service contractor.

## [1.1 PURPOSE]{.smallcaps}

1.1.1. The purpose of the QASP is to describe the systematic methods
used to measure performance and to identify the reports required and the
resources to be employed. The QASP provides a means for evaluating
whether the contractor is meeting the performance standards identified
in the PWS.

1.1.2 This QASP is designed to define roles and responsibilities,
identify the performance objectives, define the methodologies used to
monitor and evaluate the contractor's performance, describe quality
assurance reporting, and describe the analysis of quality assurance
monitoring results.

## [1.2 PERFORMANCE MANAGEMENT APPROACH]{.smallcaps}

1.2.1 The performance-based PWS structures the acquisition around "what"
service is required as opposed to "how" the contractor should perform
the work. This QASP will define the performance management approach
taken by the WRRC to monitor, manage, and take appropriate action on the
contractor's performance against expected outcomes or performance
objectives communicated in the PWS. Performance management rests upon
developing a capability to review and analyze information generated
through performance metrics. The ability to make decisions based on the
analysis of performance data is the cornerstone of performance
management. The data generated in a performance management approach
provides information that indicates whether or not expected outcomes for
required services are being achieved adequately by the contractor.

1.2.2 Performance management also represents a significant shift from
the more traditional Quality Assurance (QA) concepts in several ways.
Performance management focuses on assessing whether or not outcomes are
being achieved and migrates away from scrutiny on compliance with the
processes and practices used to achieve the outcome. The only exceptions
to process reviews are those required by law (Federal, State, and local)
and compelling business situations such as safety and health. An outcome
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 at the desired levels of
performance.

## [1.3 PERFORMANCE MANAGEMENT STRATEGY]{.smallcaps}

1.3.1 The contractor's Quality Control Plan (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 their
performance to the designated Government representative.

1.3.2 The Government representative will monitor performance and review
performance reports furnished by the contractor to determine how the
contractor is performing against communicated performance objectives.
The Government will make decisions based on performance measurement
metric data and notify the contractor of those decisions. The contractor
will be responsible for making required changes in processes and
practices to ensure performance is managed effectively.

# 2.0 ROLES AND RESPONSIBILITIES

2.1. The Contracting Officer (CO) is responsible for monitoring contract
compliance, contract administration and cost control; and resolving any
differences between the observations documented by the COR/COTR/ACO, and
the contractor's performance.

2.2 The CO will designate one full-time COR/COTR/ACO as the Government
authority for performance management. The number of additional
representatives serving as Technical Inspectors depends upon the
complexity of the services measured as well as the contractor's
performance.

2.3 The COR/COTR/ACO is responsible for monitoring, assessing, and
communicating the technical performance of the contractor and assisting
the contractor. The COR/COTR/ACO will have the responsibility for
completing QA monitoring forms (refer to Attachments 2 and 3) 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.

# 3.0 IDENTIFICATION OF SERVICES TO BE PERFORMED

The contractor shall provide operations and maintenance support in
accordance with the PWS.

The performance standards are established in the paragraph of the PWS
that covers the specific category of work. The acceptable level of
performance is set in the acceptable quality level related to that
paragraph.

# 4.0 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 In an effort to minimize the contract administration burden,
simplified methods of surveillance techniques shall be used by the
Government to evaluate contractor performance. The primary methods of
surveillance are random checks, observations, inspections, complaints
and review of those records and files that are required to be maintained
and delivered under this statement of work. The Government will use
appointed representatives, as well as reports and input from Center
employees and visitors as sources of comments on the contractor's
performance.

4.2 The contractor is expected to establish and maintain professional
communication between its employees and customers. The primary objective
of professional communication between employees and customers 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 addressing customer complaints and investigating the issues
and/or problems.

NOTE: The customer always has the option to communicate complaints to
the COR as opposed to the contractor. The COR will accept the customer
complaints and will investigate using the Quality Assurance Monitoring
Form -- Customer Complaint Investigation identified in Attachment 3.

4.3 The acceptable quality levels (AQL) located in Attachment 1,
Performance Requirements Summary Table, for contractor performance are
structured to allow the contractor to manage how the work is performed
while providing negative incentives for performance shortfalls. For
certain critical activities such as those involving facility
environment, security, chemical biological, radiological, and toxin
activities, and accident control, the desired performance level is
established at one hundred percent (100%). Other levels of performance
are keyed to the relative importance of the task to the overall mission
performance at WRRC/

# 5.0 QUALITY ASSURANCE REPORTING

5.1 The performance management feedback loop begins with the
communication of expected outcomes. Performance standards are expressed
in the PWS and measured by the required performance metrics in
Attachment 1.

5.2 The Government's QA monitoring, accomplished by the COR, will be
reported using the monitoring forms in Attachments 2 and 3. The forms,
when completed, will document the COR's understanding of the
contractor's performance under the contract to ensure that the PWS
requirements are being met.

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

# 6.0 ANALYSIS OF QUALITY ASSURANCE MONITORING RESULTS

6.1 The Government shall use the observation methods cited to determine
whether the AQLs have been met. The Government will evaluate the results
which then may be translated into the specific negative incentives that
cause adjustments to the contractor's monthly payments, should
performance not meet the AQL's.

6.2 At the end of each month, the QAS will prepare a written report for
the ACO summarizing the overall results of the quality assurance
monitoring of the contractor's performance. This written report which
consists of the contractor's submitted monthly report and the completed
Quality Assurance Monitoring Forms (Attachment II) will become part of
the QA documentation.

6.3 The ACO may require the contractor's project manager, or a
designated alternate, to meet with the ACO, QAS, and other Government
personnel as deemed necessary to discuss performance evaluation. The ACO
will define a frequency of in-depth reviews with the contractor, however
if the need arises, the contractor will meet with the ACO as often as
required or per the contractor's request. The agenda of the reviews may
discuss:

-   Monthly performance measured by the metrics and trends

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-   Issues and concerns of both parties

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-   Projected outlook for upcoming months and progress against expected
    trends

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-   Recommendations made by the QAS based on contractor information

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-   Issues arising from independent reviews and inspections

6.4 In addition to QA monitoring, the QAS will use the information
contained in the contractor's monthly report to assess the contractor's
level of performance for each objective measured in this QASP (detailed
in Attachment 1). The QAS must coordinate and communicate with the
contractor to resolve issues and concerns of marginal or unacceptable
performance. The contractor will discuss with the ACO/QAS satisfaction
ratings receiving a "less than acceptable" rating. For such cases, the
contractor should highlight its perspective on factors driving customer
satisfaction and present plans to adjust service levels accordingly to
bring the satisfaction rating up to an acceptable level.

6.5 The ACO/QAS 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. Changes to
service levels, procedures, and metrics will be incorporated as a
contract modification at the convenience of the PCO/ACO.

# 7.0. FAILURE TO PERFORM

7.1 The contractor may receive deductions or even termination based on
failure to perform. The following criteria apply for determining
appropriate action:

1.  **Notifications**. Consistent with FAR Part 49, the PCO/ACO shall
    notify the service provider of failure to meet standards through QA
    monitoring forms, cure notices, or show cause notices and shall
    inform the service provider manager or designated alternate of such
    notices.

2.  **Deductions**. The Government has the right to deduct a specified
    dollar for failure to meet performance standards. The amount is
    identified in the Required Performance Metrics (RPM) of Attachment
    I.

3.  **Termination**. If the PCO determines that the contractor has
    failed to perform to the extent that a termination for default is
    justified, the PCO shall issue a notice of termination, consistent
    with FAR Part 49.

####### ATTACHMENT I

# REQUIRED PERFORMANCE METRICS (RPM)

+----------+------------------+---------+------------+---------------+
| **       | **Performance**  | **Acc   | **Method** | **Incentive** |
| Required |                  | eptable |            |               |
| S        | **Standards**    | Qu      | **Of**     | *             |
| ervice** |                  | ality** |            | *(Negative)** |
|          |                  |         | **Surv     |               |
|          |                  | **L     | eillance** | **(Impact on  |
|          |                  | evels** |            | Contractor    |
|          |                  |         |            | Payments)**   |
|          |                  | #       |            |               |
+----------+------------------+---------+------------+---------------+
| Work     | Submit a PM      | 100%    | Files      | \$500 for     |
| Ma       | report of        |         | review,    | each          |
| nagement | scheduled,       | 90%     | periodic,  | documented    |
|          | completed and    |         | random,    | instance when |
| (See PWS | outstanding      | 95%     | obs        | a report is   |
|          | tasks monthly    |         | ervations, | submitted     |
| Section  | (PWS C.2.1.2     | 90%     | complaints | after the     |
| C.2)     | (G))             |         |            | 15^th^ of the |
|          |                  |         | Files      | month.        |
|          | Accomplish       |         | review,    |               |
|          | additional work  |         | random,    | Contractual   |
|          | in accordance    |         | complaints | remedies      |
|          | with proposed    |         |            |               |
|          | time frames      |         | Files      | Contractual   |
|          |                  |         | review,    | remedies      |
|          | Administer       |         | periodic,  |               |
|          | quality control  |         | random,    | Contractual   |
|          | program          |         | obs        | remedies      |
|          | including        |         | ervations, |               |
|          | subcontractor    |         | complaints |               |
|          | management in    |         |            |               |
|          | accordance with  |         | Files      |               |
|          | QC Plan          |         | review,    |               |
|          |                  |         | random,    |               |
|          | Submit           |         | complaints |               |
|          | management t     |         |            |               |
|          | reports as       |         |            |               |
|          | required         |         |            |               |
+----------+------------------+---------+------------+---------------+
| Admini   | Maintain         | 95%     | Files      | Contractual   |
| strative | stockroom        |         | review,    | remedies      |
| Services | inventory and    | 95%     | periodic,  |               |
|          | requisition      |         | random,    | Contractual   |
| (See PWS | items prior to   | 95%     | c          | remedies      |
|          | depleted stock   |         | omplaints, |               |
| Section  | levels           | 100%    | ob         | Contractual   |
| C.3)     |                  |         | servations | remedies      |
|          | Submit stockroom | 98%     |            |               |
|          | reports as       |         | Files      | \$500 for     |
|          | required         | 90%     | review,    | each          |
|          |                  |         | periodic,  | documented    |
|          | Deliver incoming |         | random,    | failure of    |
|          | shipments within |         | c          | noncompliance |
|          | one working day  |         | omplaints, |               |
|          | and              |         | ob         | .             |
|          | exp              |         | servations |               |
|          | ress/perishables |         |            | Contractual   |
|          | within one hour  |         | Periodic,  | remedies      |
|          |                  |         | random,    |               |
|          | Ensure visitor   |         | obs        | Contractual   |
|          | log entries are  |         | ervations, | remedies      |
|          | complete and     |         | complaints |               |
|          | visitor's escort |         |            |               |
|          | requested        |         | Periodic,  |               |
|          |                  |         | random,    |               |
|          | (PWS C.3.2 (C))  |         | obs        |               |
|          |                  |         | ervations, |               |
|          | Distribute first |         | complaints |               |
|          | class mail in    |         |            |               |
|          | same day (PWS    |         | Periodic,  |               |
|          | C.3.3 (C))       |         | random,    |               |
|          |                  |         | obs        |               |
|          | Maintain vehicle |         | ervations, |               |
|          | operation        |         | complaints |               |
|          | records on a     |         |            |               |
|          | daily basis      |         | Files      |               |
|          |                  |         | review,    |               |
|          |                  |         | random     |               |
|          |                  |         | obs        |               |
|          |                  |         | ervations, |               |
|          |                  |         | complaints |               |
+----------+------------------+---------+------------+---------------+
| Enviro   | Submit hazardous | 100%    | Files      | \$500 for     |
| nmental, | waste disposal   |         | review,    | each instance |
| Health & | logs every other |         | periodic   | when logs are |
| Safety   | month on the     |         | review,    | submitted     |
| Program  | last workday of  |         | random,    | after the     |
|          | the month (PWS   |         | obs        | last workday  |
| (See PWS | C.4.6 (A))       |         | ervations, | of the month. |
|          |                  |         | complaints |               |
| Section  |                  |         |            |               |
| C.4)     |                  |         |            |               |
+----------+------------------+---------+------------+---------------+
| Fa       | Housekeeping     | 98%     | Files/PM   | Contractual   |
| cilities | Services --      |         | review,    | remedies      |
| Services | Clean restrooms  | 90%     | periodic,  |               |
|          | on a daily       |         | random,    | Contractual   |
| (See PWS | basis; and       | 100%    | obs        | remedies      |
|          | lobbies, and     |         | ervations, |               |
| Section  | conference rooms |         | complaints | \$1,000 for   |
| C.5)     | in orderly       |         |            | each          |
|          | manner           |         | Periodic,  | occurrence of |
|          |                  |         | random,    | non           |
|          | Maintain grounds |         | obs        | certification |
|          | in acceptable    |         | ervations, |               |
|          | manner           |         | complaints |               |
|          |                  |         |            |               |
|          | Test and certify |         | Periodic,  |               |
|          | fire protection  |         | random,    |               |
|          | system in        |         | obs        |               |
|          | accordance with  |         | ervations, |               |
|          | safety           |         | complaints |               |
|          | certification    |         |            |               |
|          | requirements     |         |            |               |
|          | (PWS C.5.5 (B))  |         |            |               |
+----------+------------------+---------+------------+---------------+
| U        | Perform required | 98%     | Files      | Contractual   |
| tilities | maintenance of   |         | review,    | remedies      |
| Services | EPS and UPS      | 95%     | periodic,  |               |
| (See PWS |                  |         | random,    | Contractual   |
|          | Maintain         | 95%     | c          | remedies      |
| Section  | electrical       |         | omplaints, |               |
| C.6)     | services         | 95%     | ob         | Contractual   |
|          |                  |         | servations | remedies      |
|          | Maintain         | 100%    |            |               |
|          | te               |         | Periodic,  | Contractual   |
|          | lecommunications |         | random,    | remedies      |
|          | support          |         | obs        |               |
|          |                  |         | ervations, | \$1000 for    |
|          | Provide          |         |            | each          |
|          | plum             |         | Complaints | documented    |
|          | bing/pipefitting |         |            | instance when |
|          | services and     |         | Random,    | PM is more    |
|          | emergency shower |         | complaints | than 30 days  |
|          | maintenance/     |         |            | delinquent    |
|          | testing          |         | Periodic,  |               |
|          |                  |         | random,    |               |
|          | Perform PM,      |         | obs        |               |
|          | including water  |         | ervations, |               |
|          | treatment and    |         | complaints |               |
|          | testing, on      |         |            |               |
|          | boilers, cooling |         | Files      |               |
|          | towers,          |         | review,    |               |
|          | chillers, high   |         | periodic,  |               |
|          | purity water     |         | random,    |               |
|          | systems (PWS     |         | obs        |               |
|          | C.6.3)           |         | ervations, |               |
|          |                  |         | complaints |               |
+----------+------------------+---------+------------+---------------+

# 

# 

# 

# 

# 

# 

# ATTACHMENT II

######### QUALITY ASSURANCE MONITORING FORM

**SERVICE or STANDARD:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SURVEY PERIOD:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SURVEILLANCE METHOD (Check):** \_\_\_\_\_ Random Sampling

\_\_\_\_\_ 100% Inspection

\_\_\_\_\_ Periodic Inspection

\_\_\_\_\_ Customer Complaint

**LEVEL OF SURVEILLANCE SELECTED (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):** \_\_\_\_ Meets Standards
>
> \_\_\_\_ Does Not Meet Standards
>
> **NARRATIVE OF PERFORMANCE DURING SURVEY PERIOD:**
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**PREPARED BY:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**DATE:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# ATTACHMENT III

######### QUALITY ASSURANCE MONITORING FORM -- 

######### CUSTOMER COMPLAINT INVESTIGATION

**SERVICE or STANDARD:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SURVEY PERIOD:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**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:**
\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_ AM / PM

**CORRECTIVE ACTION TAKEN BY SERVICE PROVIDER:**
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**RECEIVED AND VALIDATED BY:**
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**PREPARED BY:**
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**DATE:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

HELPFUL HINT FROM SEVEN STEPS TEAM: Be careful not to include more
things to measure and assess than is manageable. E.g., on page 7, the
Government will assess UPS maintenance via reviewing files. It may be
easier to monitor UPS performance by observation -- either they worked
or they didn't work as needed.