Special Inspection Report

Revision: a

FIELD NAME: FIELD VALUE:
Date Report Issued:		Report Revision:
Inspection Date:		Report Number:
Arrival Time:		Client/Owner Name:
Departure Time:		Contract Number:
Weather:	Clear Cloudy Partly Cloudy	Outdoor Temperature:
Rainfall:	inch/cm	Total Time Onsite:


Inspections Performed:	Location and description of inspection methods and procedures performed by Company and/or Subcontractors
Name/ID# of Contract Inspector(s):	When Applicable
Contract Inspector Signature:	Typed-In Name is a Secure Signature	Date:
Inspection and Test Data from Non-Accredited Sources:
Review of Material Certification Records:	See AC291 Appendix A
Structure/Item Inspected:	List Codes, Specifications, Standards, Construction Documents
Deviations:	Deviations/Additions/Exclusions/Omissions from the Agreed Methods and Procedures, and Caveats/Assumptions
Previous Inspection Discrepancy(s):	Resolution of Discrepancies Noted from Previous Inspection
Results of Inspection(s):	List Company and Contract Inspector names, Subcontractor attachments, and nonconformities


Description of Samples:
Sampling Method:	ANSI Z1.4 or C=0
Sample Details:	Where When How Whom
Sample Quantity:
Sample Dimensions:
Sample Characteristics:
Laboratory Traceability:	List Names of Laboratories and each Chain of Custody Number
Inspection Equipment:	List Monitoring and Measurement Equipment
Remarks:


Statement of Conformity
We hereby certify special inspections were completed according to the Contract Number stated above and relate exclusively to the work ordered and structure/items inspected. Results of all chemical and physical tests are on file as well as related documented information, which are available for review by the Client according to the above Contract and related Specifications.
Authorized Approval Signature:		Date:
Inspector Name/ID Number:		Training Renewal Date:
Inspector Mark/Seal:		Inspector Mark/Seal Expiration:


Below is for Company Use Only
Completion of Desktop Review / Onsite Review
Desktop Review
Desktop Reviewer Name:
Desktop Reviewer Signature:		Date:
Onsite Review
Onsite Reviewer Name:
Onsite Reviewer Signature:		Date:

PaperlessEfficient QMS™Created by: qualitycontrolplan.com

Special Inspection Report

Paperless
Efficient QMS™
Created by: qualitycontrolplan.com