Standard Form 368, Product Quality Deficiency Report, October 1985

PRODUCT QUALITY DEFICIENCY REPORT
1a. FROM (Originator)
1c. DATE
4. DATE DEFICIENCY
DISCOVERED
7a. MANUFACTURER/CITY/STATE
2b. NAME, TELEPHONE NO. AND SIGNATURE
5. NATIONAL STOCK NO. (NSN)
7b. MFRS. CODE
7c. SHIPPER/CITY/STATE
10a. CONTRACT NO.
11. ITEM
12. DATE RECD., MFRD., REPAIRED,
OR OVERHAULED
13. OPERATING TIME AT FAILURE
a. RECEIVED
b. INSPECTED
REPAIRED/
OVERHAULED
15. QUANTITY
16. DEFICIENT
ITEM
WORKS
ON/WITH
a. END ITEM
(Aircraft,
mower,
etc.)
b. NEXT
HIGHER
ASSEMBLY
17. UNIT COST
$
2c. DATE
6. NOMENCLATURE
9. SERIAL/LOT/BATCH NO.
NEW
CATEGORY II
2a. TO (Screening point)
1b. NAME, TELEPHONE NO. AND SIGNATURE
3. REPORT CONTROL NO.
CATEGORY I
10b. PURCHASE ORDER NO.
8. MFRS. PART NO.
10c. REQUISITION NO.
10d. GBL NO.
14. GOVERNMENT FURNISHED MATERIAL
YES
c. DEFICIENT
NO
d. IN STOCK
(1) TYPE/MODEL/SERIES
(2) SERIAL NO.
(1) NATIONAL STOCK NO. (NSN)
(2) NOMENCLATURE
18. ESTIMATED REPAIR COST
19a. ITEM UNDER WARRANTY?
$
YES
NO
(3) PART NO.
(4) SERIAL NO.
19b. EXPIRATION DATE
UNKNOWN
20. WORK UNIT CODE/EIC (Navy and Air Force Only.)
21. ACTION/DISPOSITION
RELEASED FOR
RETURNED
DISPOSED
OTHER (Explain
REPAIRED
INVESTIGATION
TO STOCK
OF
in Item 22)
22. DETAILS (Describe, to best ability, what is wrong, how and why, circumstances prior to difficulty, description of difficulty, cause, action taken, including
disposition, recommendations. Attach copies of supporting documents. Continue on separate sheet if necessary.)
HOLDING EXHIBIT FOR
DAYS
23. LOCATION OF DEFICIENT MATERIAL
24a. TO (Action Point)
24b. NAME, TELEPHONE NO. AND SIGNATURE
25a. TO (Support Point) (Use Items 26 and 27 if more than one)
24c. DATE
26a. TO (Support Point)
26b. NAME, TELEPHONE NO. AND SIGNATURE
368-102
NSN 7540-00-133-5541
25b. NAME, TELEPHONE NO. AND SIGNATURE
25c. DATE
27a. TO (Support Point)
26c. DATE
27b. NAME, TELEPHONE NO. AND SIGNATURE
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27c. DATE
STANDARD FORM 368 (REV. 10-85)
GENERAL SERVICES ADMINISTRATION
(FPMR 101-26.8)
28. FINDINGS AND RECOMMENDATIONS OF INVESTIGATION. (Explain in detail. Continue on a separate sheet of paper, if necessary.)
29. ACTION TAKEN
30. RESULTS OF DEPOT SURVEILLANCE
INSTRUCTIONS
1a. FROM (Originator) - Complete name of activity (no acronyms when
sending deficiency report across component lines), activity address code
(ACC), address including zip code of the activity originating the report.
1b. NAME, TELEPHONE NO., AND SIGNATURE - Provide name, telephone no., (include all available telephone numbers; FTS; Autovon, and
commercial) and signature of an individual who can serve as a contact for
questions regarding the report and/or to request exhibits or samples.
1c. DATE - Enter date report was signed and forwarded to the screening
or action point.
2a. TO (Screening Point) - The originating point will complete name of
the screening point activity (no acronyms when deficiency report will be
sent across component lines), the activity address code (AAC), address
including zip code of the screening point where the report needs to be
sent by the originator's activity. For those activities that do not have
screening points, leave blank.
2c. DATE - Enter the date the person finished processing the report at
the screening point.
3. REPORT CONTROL NUMBER - Number assigned to report when a
numbering system is used. Those activities which are reporting quality
deficiencies across component lines and are to comply with the DLA
Regulation 4155.24 should reference the report control number as
prescribed in the regulation.
7a. MANUFACTURER/CITY/STATE - Name of the manufacturer, the
maintenance contractor, or Government activity which last repaired or
overhauled the deficient item. For motor vehicles or components thereof,
enter name of manufacturer of the vehicle or component, as appropriate.
13. OPERATING TIME AT FAILURE - Time item had been in operation
since new, overhauled, or repaired when the deficiency was
discovered, citing the appropriate performance element (miles, cycles,
hours, etc.).
15c. QUANTITY DEFICIENT - Enter the quantity found deficient of
those inspected.
15d. QUANTITY IN STOCK - Enter the quantity of material from the
same manufacturer remaining in stock.
17. UNIT COST - Dollar value of the deficient item when known. Not
applicable on reporting vehicles to GSA.
18. ESTIMATED REPAIR COST - Unit cost times number of units for
replacement or estimated repair costs (including overhead) times
number of units for correcting all the deficient items reported when it
can readily be determined. Not applicable on reporting vehicles to
GSA.
19. ITEM UNDER WARRANTY - Check if item is known to be covered
by contractor warranty. If yes, provide expiration date.
21. ACTION/DISPOSITION - A check in the appropriate block to
indicate the action taken or requested. When an exhibit or sample is
being held, indicate the number of days in the space provided. (An
exhibit or sample shall be held for a minimum of 30 calendar days
from date the report is transmitted to the action point. Reporting
activities are reminded that the packaging, packing and shipping
containers are to be held along with the exhibits to facilitate
investigation.) When none of the items indicate the actions or
disposition taken or requested, check "Other" and identify the nature
of the action taken or requested in item 22.
7b. MANUFACTURER'S CODE - Code of the manufacturer as listed in
Cataloging Handbook H4.1 (Name to code), Federal Supply Code for
Manufacturers (United States and Canada).
23. LOCATION OF DEFICIENT MATERIAL - Address and location of
deficient material.
7c. SHIPPER/CITY/STATE - When the shipper of an item is different from
the manufacturer, also include the shipper's or supplier's name.
24a. TO (Action Point) - Name, in the clear address, including zip code
of the action point to which the report is being submitted.
9. SERIAL/LOT/BATCH NO. - Manufacturer's serial, lot, or batch number
of deficient item as applicable.
24c. DATE - Enter the date the report was forwarded to an action
point or the date the findings and recommendations were completed.
10. CONTRACT, PURCHASE ORDER, REQUISITION; GOVERNMENT BILL
OF LADING (GBL) NO. - Enter these numbers or any other available transportation document number in lieu of the GBL. Such numbers appear on
the container, purchase document and/or the item. It is extremely helpful
if these items are furnished when the material was supplied by GSA.
28. FINDINGS AND RECOMMENDATIONS OF INVESTIGATION Include the findings and recommendations for resolution of complaint.
11. ITEM - Check the appropriate block; provide the dates manufactured
and received in Block 12, if available.
29. ACTION TAKEN - State the action taken to resolve the complaint.
30. RESULTS OF DEPOT SURVEILLANCE - Show results of depot
surveillance and planned action (i.e. replacement or repair by
contractor, disposal, issue, etc.).
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STANDARD FORM 368 BACK (REV. 10-85)