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OMB Number: 0910-0909 Exp Date: XX/XX/XXXX See bottom of page for PRA statement |
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Contract Number (auto-filled) |
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Select Agency |
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Agency Name (select from list) |
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Select |
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State or US Territory (auto-filled) |
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Select Agency |
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Contract Type |
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EGG |
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Date Completed (MM/DD/YYYY) |
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State Report Preparer's Name |
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State Report Preparer's Email |
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Period of Performance Start Date |
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Period of Performance End Date |
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Reporting Period Start Date |
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Reporting Period End Date |
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Reporting Period Frequency |
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Select |
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Current Reporting Period |
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Select |
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Contract Reporting Elements |
Line Item (for current option) |
Total Contract Requirement |
Total Completed (this reporting period) |
Total Remaining |
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Contract Work Accomplished |
Contract Inspection Types |
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1. Target Inspections |
0 |
0 |
0 |
0 |
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2. Visits (Out-of-Business, etc.) |
0 |
0 |
0 |
0 |
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Contract Samples |
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3. Evironmental Samples |
0 |
0 |
0 |
0 |
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4. In-Compliance Quantity |
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0 |
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5. Not In-Compliance Quantity |
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0 |
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6. Other - Training |
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0 |
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State Contract Actions |
7. Enforcement Notices (e.g. warning letters) |
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0 |
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8. Embargoes/Seizures |
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0 |
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9. Hearings Conducted |
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0 |
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10. Prosecutions/Injunctions |
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0 |
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Other Contract Actions List Below |
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11. [Replace bracketed text] |
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0 |
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12. [Replace bracketed text] |
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0 |
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13. [Replace bracketed text] |
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0 |
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14. Re-Inspections (Follow-ups to violative Inspections) |
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0 |
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State Contractor Challenges, Issues, and Highlights |
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15. Select the current status based on your assessment of contract performance for this reporting period. |
Select |
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16. List any major challenges encountered this reporting period and corrective actions taken. Include how these actions directly address those challenges.
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17. Write a brief narrative detailing any positive, significant events identified during this reporting period.
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18. If applicable, report a dollar value for Item 8. Embargos/Seizures from the table above. |
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19. Additional State Reporting Comments
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Contract Performance Feedback |
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20. Indicate the overall status of the State contractor's performance this reporting period. |
Select |
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21. (Optional) If the contractor experienced challenges or issues during this reporting period, please list them and detail any corrective actions taken or agreed to by the contractor.
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22. (Optional) Write a brief narrative detailing any positive, significant events identified during the contractor's performance this reporting period.
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23. Indicate Division Approval or Disapproval by selecting from the drop-down menu. If this report is disapproved, provide your explanation below. |
Select |
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24. (Optional) Additional Division Reporting Comments.
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25. Enter the name of the Division Representative approving this report. |
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26. Enter the date this Division Review was completed. |
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