Roads 11292016 Qa Form Revised

Republic of the Philippines
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

DILG - NAPOLCOM Center, EDSA Corner Quezon Avenue, Quezon City
www.dilg.gov.ph

QUALITY ASSURANCE SUMMARY REPORT No. ___

(Date of Visit)
I. Basic Project Data

Description
Province
Project Name
Project ID
Project Length (km) Thickness (mm)
Project Width (m)
Project Station Limits Beginning End
Original Contract Amount
Revised Contract Amount (if applicable)
Contract Duration
Rev Contract Duration (if applicable)
Start Date
Orig Intended Completion Date
Rev Intended Completion Date (if applicabl
II. Project Accomplishment
Reporting Cut-off Date Planned Actual Variance
As of (Date)
III. Current Findings and Observations**
Risk Level* (H, M, L)
Summary of Current Findings/ Observations Recommendation/s
Time Quality
No proper documentation on Monthly Advise PEO to produce month
Accomplishment and Materials Report L H accomp & materials report
Frequent absence of contractors Materials Advise PEO to instruct contra
Engineer/ Laboratory technicians to mobilize quality control
H H personnel as required in the
contract
Insufficient warning signs at jobsite Advise PEO to issue site

L L instruction on the provision
adequate warning signs
No preliminary quality test for subbase Advise PEO to issue site
course materials M H
instruction on the conduct of
Excess excavated materials behind toe of quality
Advise test
PEOfor
to subbase
issue sitemateri
grouted riprap not disposed or levelled L L instruction on proper disposal
excavated
**Should include previous findings/observations if no action was taken yet. Mustmaterials
be supported by
photos/relevant documents.
IV. Previous Findings and Observations
Summary of Previous Findings/ Observations Actions Taken/ Status Remarks
V. Inspectorate Team
Name of Inspector Position Signature
*Risk Level
High (H) - Will cause substantial delay on construction progress; has significant effect on construction quality
Medium (M)- Will cause minimal delay on construction progress; has minor effect on construction quality
Low (L) - Will not cause any delay on construction progress; has no effect on construction quality
Republic of the Philippines
THE INTERIOR AND LOCAL GOVERNMENT
LCOM Center, EDSA Corner Quezon Avenue, Quezon City
www.dilg.gov.ph
SURANCE SUMMARY REPORT No. ___

(Date of Visit)
Page ___ of ___
Thickness (mm)
Remarks
Recommendation/s
Advise PEO to produce monthly
accomp & materials report
Advise PEO to instruct contractor
to mobilize quality control
personnel as required in the
contract
Advise PEO to issue site

instruction on the provision
adequate warning signs
Advise PEO to issue site
instruction on the conduct of
quality
Advise test
PEOfor
to subbase
issue sitematerials
instruction on proper disposal of
excavated
s/observations if no action was taken yet. Mustmaterials
be supported by
Remarks
Signature
construction progress; has significant effect on construction quality

n construction progress; has minor effect on construction quality
struction progress; has no effect on construction quality
Department of the Interior and Local Government
Office of Project Development Services
Konkreto at Ayos na Lansangan ang Daan Tungo sa Pangkalahatang Kaunlaran (KALSADA)
QUALITY ASSURANCE REPORT No. ____

(Documentation)
(Date of Visit)
Province: ______________________________________________________________________
Name of Project: _______________________________________________________________
Project Code: __________________________________________________________________
Description Requirement Compliance Status
I. Approved Plans & Bill of Quantities
1 Contract Plan (as bid) Check approval/ signatures/ completeness
2 As-staked Plan & Quantities Check approval/ signatures/ completeness/

survey notes/ changes in original plan/
quantity calculations
3 As-built Plan & Quantities Check approval/ signatures/ completeness/

survey notes/ changes in as staked plan/
not applicable during construction/
quantity calculations
4 Shop Drawings (if any) Check approval/ signatures/ completeness/

compliance with standards
II. Contractor's Personnel

1 Contractor's Organizational Chart Check if personnel are the same as
proposed in the bid; if there are changes,
check if replacement has been approved
III. Construction Schedules

1 Updated Construction Schedule/S- Check completeness/ approval/ sequence
curve of activities/ consistency with latest
approved BOQ
2 Updated Equipment Utilization Check completeness/ approval/ availability

Schedule of equipment based on schedule
3 Updated Workforce Schedule Check completeness/ approval/ availability

of personnel based on schedule
4 Updated PERT/CPM Check completeness/ approval/ sequence

of activities/ consistency with contract
duration
5 Updated Straight Line Diagram Check consistency with plans and BOQ
IV. Materials Quality Control
1 Quality Control Plan Check completeness/ approval/
consistency with BOQ/ compliance with
specifications & standards
2 Materials Log Book Check availability of documentation

3 Monthly Materials Test Reports Check completeness/ approval/ results/
compliance with quality control plan
4 Worksheets Check availability of documentation
5 Presence of Materials Engineer Check availability/ verify mobilization
schedule
V. Communications
1 Site Instructions Check availability of documentation

(Documentation)
(Date of Visit)
Province: ______________________________________________________________________
Name of Project: _______________________________________________________________
Project Code: __________________________________________________________________
2 Approved Work Requests/Pouring Check availability of documentation
Permits
3 General Correspondence Check availability of documentation
VI. Progress Reporting
1 Weekly Progress Report Check availability of documentation
2 Monthly Progress Report Check availability of documentation
3 Progress Photographs Check availability of documentation
4 DILG Data Capture & Progress Check availability of documentation
Monitoring Report
VII. Contract Amendments/Variations
1 Approved Variation Orders Check completeness of documentation/
validity of justifications
2 Approved Time Extensions Check completeness of documentation/
3 Approved Time Suspensions Check completeness of documentation/
VIII. Meetings
1 Minutes Check availability of documentation
2 Attendance Sheets Check availability of documentation

(Documentation)
(Date of Visit)
Province: ______________________________________________________________________
Name of Project: _______________________________________________________________
Project Code: __________________________________________________________________
IX. Environment, Health and Safety
1 Construction Safety and Health Check availability of documentation;
Program compliance with CSH standards of DOLE
2 First Aid Kit Check availability at project site
3 Presence of Safety Officer Verify presence at project site
4 Traffic Management Plan (signs, Check if appropriate traffic management
flagperson, etc) plan is being enforced
5 Warning signs Check adequacy of warning signs
6 Barricades(lighting fixtures, Check adequacy of barricades
reflectorized signages,cones, etc)
7 Protective Personal Equipment Check if contractor's personnel has
appropriate PPEs
X. Insurance/ Securities
1 Contractor's All Risks Insurance Check availability of documentation/ must
cover acts of nature and valid up to end of
DLP
2 Performance Security Check availability of documentation/ must

not be lesser than contract price and valid
up to end of DLP
3 Advance Payment Security Check availibility of documentation if

advance payment is made/ must not be
lesser than the amount advanced and valid
up to full recoupment
XI. Progress Monitoring/ Inspections

1 Copy of Inspection Reports/Punchlist Check availability of documentation
2 Notice to Rectify Check availability of documentation (when

defects were noted)
3 CPES Results Check availability of documentation/
conduct of CPES must comply with CPES
Guidelines by NEDA
4 Project Logbook/ Daily Instructions and Check availability of documentation

Accomplishment Log
XII. Billings
1 Approved billings Check availability of documentation for all
payments made
XI. Contract Documents
1 Signed Contract Agreement Check availability of documentation/ must
be notarized
2 Notice to Proceed Check availability of documentation/ must
indicate effective date of contract
3 Notice of Award Check availability of documentation

(Documentation)
(Date of Visit)
Province: ______________________________________________________________________
Name of Project: _______________________________________________________________
Project Code: __________________________________________________________________
4 Technical Specifications Check availability of documentation/ must
be based on DPWH Blue Book
5 Others Include contractor's original bid & other
contract documents
* Indicate whether:
Fully Complied
Partially Complied
Not Complied
No basis
ent of the Interior and Local Government
ce of Project Development Services
an ang Daan Tungo sa Pangkalahatang Kaunlaran (KALSADA)
LITY ASSURANCE REPORT No. ____

(Documentation)
(Date of Visit)
Page ___ of ___
Remarks

(Documentation)
(Date of Visit)
Page ___ of ___
Remarks

(Documentation)
(Date of Visit)
Page ___ of ___
Remarks

(Documentation)
(Date of Visit)
Page ___ of ___
Remarks
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:
Accomplishment Quality Compliance Check

Accomp
Item of Work Description Unit Original Qty Completed Compliance Area
Rate
100 Clearing and Grubbing ha Construction limit
Stump holes
Disposal requirements
Quantification
101 Removal of Existing Structures ea Traffic management
Disposal requirements
Quantification
102 Excavation cu.m. Quality of cut surface
Finished grade
Completion of prior works
Utilization of excavated materials
Disposal of unsuitable materials
Quantification
103 Structure Excavation cu.m. Completion of prior works
Utilization/disposal of excavated materials
Quantification
104 Embankment cu.m. Clearing and grubbing have been completed
Suitable materials were used
Proper construction methodology applied and compaction trials
completed prior before commencing subsequent sections.
Work volume properly quantified
105 Subgrade Preparation sq.m. All culverts, cross drains, ducts and the like, ditches, drains and drainage
outlets have been completed
Finished compacted surface of the subgrade has conformed to allowable
tolerances (permitted variation from design level of surface +20/-30,
variation from design crossfall +/-0.5%, variation from longitudinal grade
+/-0.1% over 25m length.
Quantities have been properly quantified/ measured

(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
200 Aggregate Subbase Course cu.m. Materials have passed the grading requirements (checked sieve analysis)
Materials have passed liquid limit (35) and plasticity index (12)
Materials passing No. 10 sieve have passed LA Abrasion Tests (50)
Materials have passed density test (soaked CBR value>30%)
Existing surface has been graded and finished as provided under Item
105
Maximum layer of 150mm
Moisture content has been monitored (watering done as necessary)
Trial section (500sq.m) compliant with field density requirements
completed
Finished compacted surface does not exceed the allowable tolerances: (i)
thickness of layer +/-20mm, level of surface +10mm/-20mm, surface
irregularity 20mm, crossfall +/-0.3%, longitudinal grade +/-0.1%
Quantities properly calculated

201 Aggregate Base Course cu.m. Materials have passed the grading requirements
Materials (passing No 40) have passed liquid limit (25) and plasticity
index (6)
Materials passing 19mm sieve have passed density test (soaked CBR
value>80%)
105
completed
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate

202 Crushed Aggregate Base Course cu.m. Materials have passed the grading requirements
Materials passing No 40 have passed liquid limit (25) and plasticity
index (6)
Materials passing 19mm sieve have passed density test (soaked CBR
value>80%)
105
completed

(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
300 Aggregate Surface Course cu.m. Materials have passed the grading requirements (check sieve analysis)
Materials have passed liquid limit (<35) and plasticity index (4-9)
requirements (check test results)
Materials have achieved CBR value of not less than 80% (check test
results)
Materials have been placed and compacted in accordance with the
requirements of Item 201
completed
thickness of layer +15/-5mm, level of surface +15mm/-5mm, surface
irregularity 5mm, crossfall +0.2%, longitudinal grade over 25m = +0.1%

311 Portland Cement Concrete Pavement sq.m. Materials (cement, sand, gravel, water) have passed quality test
Mix design has passed the flexural and compressive strength tests
Submission of Quality Control Plan
Longitudinal and weakened plane joints properly sawed
Three (3) concrete beam test specimens (150x150x525mm) have been
made, cured and have passed required tests for every 330sq.m of
pavement
Pavement shall have passed surface test (smoothness) with surface

deviations not exceeding 12mm for every 12m length
Concrete properly cured
Joints properly sealed with asphalt sealant
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
Load transfer device (dowel) is in accordance with specs and properly
placed
404 Reinforcing Steel kgs. Materials have passed strength test
Order list and bending diagram approved by Engineer
Reinforcing steel stored above the surface of the ground using platform
or other supports
Reinforcing steel properly placed, spliced and fastened
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
405 Structural Concrete cu.m. Materials (cement, sand, gravel, water, reinforcing) have passed quality
or strength test
Three (3) concrete cylinder test specimens (150x300mm) have been
made, cured and have passed required tests for every 75cu.m of
concrete or fraction thereof placed each day

407 Concrete Structures each Materials (cement, sand, gravel, water, reinforcing) have passed quality
or strength test
Three (3) concrete cylinder test specimens (150x300mm) have been
made, cured and have passed required tests for every 75cu.m of
concrete or fraction thereof placed each day
Alignment and dimensions in accordance with plans
500 Pipe Culverts and Storm Drains l.m. Materials (cement, sand, gravel, RCPC, etc) have passed required quality
or strength test
Alignment, grade and dimensions in accordance with plans
Backfill materials in accordance with specs and compacted to the density
required under Item 104
502 Manholes, Inlets and Catch Basins Each Materials (cement, sand, gravel, water) have passed required quality or
strength test
503 Drainage Steel Grating with Frame set Materials (steel grating, steel frame) are in accordance with the required
size, quality or strength test
Concrete construction conforms to requirements of Item 405 Structural
Concrete
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
505 Riprap and Grouted Riprap cu.m. Materials (stones) are in accordance with the required sizes and quality

Mortar shall conform to the requirements of Item 405 Structural
Concrete with min thickness of 20mm
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
506 Stone Masonry cu.m Materials (stones) are in accordance with the required sizes (not less
than 150mm thick & width not less than 1.5 times the thickness) and
quality

Mortar shall conform to the requirements of Item 405 Structural
Concrete with min thickness of 20mm
600 Curb and Gutter l.m. Materials for bed course passes through 12.5mm sieve.
Concrete construction shall conform to the requirements of Item 405
Structural Concrete
601 Sidewalk sq.m. Materials have passed required quality tests.
Structural Concrete
605 Road Signs each Materials shall be aluminum sheeting at least 3mm thick.
Signs shall comply with DPWH Highway Safety Design Standards
Structural Concrete
Nuts and bolts are hot-dip galvanized
Sign panel installed in accordance with plans
606 Pavement Markings sq.m. Paint applied are in accordance with the size, shape and location of the
markings shown on the plans.
TOTAL
(Physical Works)
(Date of Visit)
Province:
Name of Project:
Project Code:

Accomp
Rate
Overall Quality Assessment

Very
Assessment Area Satisfactory Poor
Satisfatory
Materials
Workmanship
Dimensions/alignment
Measurement of quantities
Work schedule
Environmental/ safety and health
Suggested assessment parameters:

Very Satisfactory: Has substantially complied all requirements of the contract.
Satisfactory: Has complied most requirements of the contract but with minor deviations.
Poor: Has poor compliance with requirements of the contract and needs substantial improvement and close supervision and frequent monitoring.
tment of the Interior and Local Government
ngan ang Daan Tungo sa Pangkalahatang Kaunlaran (KALSADA)
ALITY ASSURANCE REPORT No. ____
(Physical Works)
(Date of Visit)
Page ___ of ___
Quality Compliance Check

Assessment* Remarks/Recommendations
(Physical Works)
(Date of Visit)
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(Date of Visit)
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(Date of Visit)
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* Indicate whether:
Fully Complied
Partially Complied
Not Complied
No basis
Comments / Suggestion for QA Form (Roads and Bridges):
- Recommended for big ticket project (Above 5M)

- Inspectorate team
- Provide additional space for:
DILG Inspectorate Team
LGU Representatives
Contractor Representative
- Indicate whether: (Include definition of the following)

Fully Complied
Partially Complied
Not Complied
No basis
- Indicate Page Number
- Suggestion: Protocol
- After inspection, conduct exit conference with LCE or LCE Representative (from DILG-RO)
- DILG will be the only signatory. DILG to formally transmit findings to LGU (from DILG-OPDS
-Sir Mike Gler)

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Roads 11292016 Qa Form Revised

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Formate disponibile

Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

QUALITY ASSURANCE SUMMARY REPORT No. ___

I. Basic Project Data

Insufficient warning signs at jobsite Advise PEO to issue site

Summary of Previous Findings/ Observations Actions Taken/ Status Remarks

SURANCE SUMMARY REPORT No. ___

Advise PEO to issue site

construction progress; has significant effect on construction quality

QUALITY ASSURANCE REPORT No. ____

2 As-staked Plan & Quantities Check approval/ signatures/ completeness/

3 As-built Plan & Quantities Check approval/ signatures/ completeness/

4 Shop Drawings (if any) Check approval/ signatures/ completeness/

II. Contractor's Personnel

III. Construction Schedules

2 Updated Equipment Utilization Check completeness/ approval/ availability

3 Updated Workforce Schedule Check completeness/ approval/ availability

4 Updated PERT/CPM Check completeness/ approval/ sequence

2 Materials Log Book Check availability of documentation

QUALITY ASSURANCE REPORT No. ____

QUALITY ASSURANCE REPORT No. ____

2 Performance Security Check availability of documentation/ must

3 Advance Payment Security Check availibility of documentation if

XI. Progress Monitoring/ Inspections

2 Notice to Rectify Check availability of documentation (when

4 Project Logbook/ Daily Instructions and Check availability of documentation

QUALITY ASSURANCE REPORT No. ____

LITY ASSURANCE REPORT No. ____

LITY ASSURANCE REPORT No. ____

LITY ASSURANCE REPORT No. ____

LITY ASSURANCE REPORT No. ____

Accomplishment Quality Compliance Check

Quantities have been properly quantified/ measured

Accomplishment Quality Compliance Check

Quantities properly calculated

Accomplishment Quality Compliance Check

Quantities properly calculated

Quantities properly calculated

Accomplishment Quality Compliance Check

Quantities properly calculated

Pavement shall have passed surface test (smoothness) with surface

Accomplishment Quality Compliance Check

Accomplishment Quality Compliance Check

Quantities properly calculated

Accomplishment Quality Compliance Check

Alignment and dimensions in accordance with plans

Accomplishment Quality Compliance Check

Alignment and dimensions in accordance with plans

Accomplishment Quality Compliance Check

Overall Quality Assessment

Suggested assessment parameters:

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Quality Compliance Check

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Quality Compliance Check

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Quality Compliance Check

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Quality Compliance Check

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Quality Compliance Check

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Quality Compliance Check

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