Derco QA Supplier Survey

QUALITY ASSURANCE SUPPLIER EVALUATION SURVEY

Please note that all fields must be completed in order to submit this form.

Company Name:		Facility Area (Sq. Ft.):
Address:		Number of Employees:
City:	State:Zip:	Contact Name:
Country:		Contact Name Title:
Company Phone:		Contact Name Email:
Company Fax:		Contact Name Phone:
Company Website:


QUALITY SYSTEM
The quality system is derived from a quality assurance specification as follows:
	FAR 21 FAR 145 ISO 9001:_____ AS 7104 NADCAP AC 00-56 AS 9100 AS 9110 AS 9120 EASA Certificate
	FAA issued "Repair Station Operations Specs" Incl A449 Form Transport Canada MRO Certificate
	Other (Specify):

PLEASE PROVIDE EVIDENCE OF APPROVAL / ACCREDITATION USING ONE OF THESE OPTIONS:
If Accredited, please choose one of these options for submitting your evidence -- otherwise skip to Not Accredited statement below:
	* I will email our evidence of approval/accreditation by using the browser application after submitting this form**
	* I will email our evidence of approval/accreditation separately**
	* I will fax our evidence of approval/accreditation to Fax# 860-998-9129 **

If Not Accredited, indicate if you are compliant and to what system:


INDICATE ALL TYPES OF BUSINESS THAT APPLY
Manufacturer	Distributor	Repair Facility	Service Provider


PLEASE DESCRIBE THE TYPES OF PRODUCTS OR SERVICES YOU SUPPLY:


PLEASE CHECK ALL CATEGORIES THAT APPLY TO TYPES OF PRODUCTS & SERVICES YOU PROVIDE
1 - Avionics Equipment, Components, and Products: Electronic equipment and components: Flight data computers, transponders, antennas, altimeters, voice recorders, instruments and gauges, digital display, indicators, gyros, etc.
2 - Raw Stock Materials: Sheet metal, extrusions, rods, bars, tubing, nonmetallic materials such as carpets, fabrics, lexan, shim material, phenolic material, spiral wraps, foam sheets, rubber, castings and forgings, angles, etc.
3 - Aerospace Fasteners and Related Hardware: Nuts, bolts, screws, etc of all specifications AN, NAS, MS, and other similar small components: nuts, bolts, clamps, rivets, pins, washers, sockets, nut plates, screws, studs, spacers, retaining rings, clevis, clips helicolis, cotter pins, elbows, tees, inserts, specialty hardware, dzus fasteners, camlocs, springs, Hylocs, etc.
4 - Electrical Devices & Wiring: Electrical components, assemblies and parts: wiring, jumpers, connectors, light bulbs, switches, terminal studs, shrink tubing, circuit breakers, wire harnesses, adapters, backshells, contacts, pins, collars, diodes, cable assemblies, fuses, dimmers, micro switches, potentiometers, receptacles, solenoids, splices, thermocouples, leads, lacing cords, sleeving, brushes, batteries, electrical cable/wire, etc.
5 - GSE: Tape, tools, flight simulators and programs, desktop computers and parts, protective caps, safety wire, etc.
6 - Service Provider and Sub-contractors: Calibration services, repair facilities, engineering services, technical data services, NDT inspection services, cadmium plating, manganese phosphate coating, chrome plating, zinc plating, stator and rotor rewinding, aluminum oxide coating, machine shop services (machining), CMM inspection, nickel plating, anodizing, balancing, hydraulic component & module repair, pneumatic component & module repair, electronic component & module repair, electric component & module repair, mechanical component & module repair, sheet-metal & structural airgrame component repair, hydraulic fluid contamination check, shot-peening, etc.
7 - Rotable, Non-Avionics, Non-Electrical Components: Hydraulic pumps, actuators, flap, rudder, tires & wheels, brakes, seats, safety equipment, motors, generators, landing gear, fans, engine parts, fire extinguishers, oil coolers, oxygen bottles, rafts, slides, oxygen generators, Fuel systems, engines, power plant, propellers, environmental control system, etc.
8 - Non-Rotable, Non-Avionics, Non-Electrical Components: Couplings, hoses, interior parts, hydraulics fittings, galleys and galley accessories, lavatories, air ducts, link assemblies, squibs, counter weights, regulators, windshield, bushing, bearing and components, non-electrical cables/control cables, seals, o-rings, packings, gaskets, elastomers, filters, plugs, igniters, belts, deice boots, placards, decals, stencils, straps, wipers, insulation blankets, tubes, tube assemblies, equipment and furnishings, etc.
9 - Structural Assemblies, Components & Parts: Longerons, brackets, fittings, hinges, hooks, cowlings, floorboards, panels, ceilings, vents, vanes, chine caps, beams, airframe, etc.
10 - Chemical Materials, Finishes & Aerospace Fluids: Primers, paints, sealants, corrosion inhibiting compounds, cleaners, abrasives, cements, glue, solvents, hydraulic fluids, engine oils, grease, gases, degreasers, gear oil, lubricants, etc.


GOVERNMENT
Cage Code:	% of Sales to the U.S. Government:
SIC Code(s):

Government Quality Representative (QAR):(Please check one option)	Itinerant	Resident

NAME:	PHONE:


Has your company ever been debarred from U.S. government procurement?Yes No
If yes please explain:


CERTIFICATION / TRACEABILITY AND MATERIAL CONTROL
Does your company provide a Certificate of Conformance (CoC) with each shipment containing an Authorized Signature and the following:	Yes	No	N/A
Part Number	Yes	No	N/A
Condition of Part	Yes	No	N/A
Derco's Purchase Order Number	Yes	No	N/A
Revision Level	Yes	No	N/A
Name of Manufacturer	Yes	No	N/A
Lot/Batch Numbers(s) or serial number	Yes	No	N/A

DOES YOUR COMPANY PROVIDE THE FOLLOWING INFORMATION WHEN APPLICABLE?
Quality requirements can be viewed online please visit http://www.dercoaerospace.com/business_supplier_terms.htm and click on Quality Codes
Cure Date, Date of Manufacture or Lube Date for life limited items	Yes	No	N/A
Shelf Life Data for life limited items	Yes	No	N/A
Are life limited materials shipped with a minimum of 75% shelf life remaining?	Yes	No	N/A
Do you provide pull test data for Control Cables?	Yes	No	N/A
Do you provide pressure test data for hoses?	Yes	No	N/A
Are calibration standards traceable to NIST?	Yes	No	N/A
Do your procedures define the facilities and environments for calibration, handling, control, storage, and maintenance of all measuring and test equipment?	Yes	No	N/A
Are Material Safety Data Sheets (MSDS) supplied with hazardous, volatile or toxic material?	Yes	No	N/A
If a repair station: Does the repair station meet the Antidrug and Alcohol Misuse Prevention Program to which each employee who performs a safety-sensitive function, directly or by contract, including by sub-contract at any tier, is in compliance with the amended Anti-drug and Alcohol Misuse Prevention program requirements described in 14 CFR part 120	Yes	No	N/A
Overhauled components include airworthy maintenance release or 8130-3 tags along with work order/tear down reports?	Yes	No	N/A

RECORDS OF TRACEABILITY
Records of traceability are kept for years, and (will be provided / are available for review) when requested. (Please check one option)
Is lot/batch segregation maintained? *If NO or N/A, then please describe how traceability is maintained:	Yes	No	N/A

Do you have recall capabilities for non-conforming products?	Yes	No	N/A
Does your system assure that Overhauled, Repaired, Repairable, or As Removed parts have not been exposed to extreme heat and/or stress?	Yes	No	N/A


COUNTERFEIT PARTS
Does your company have a counterfeit parts program in place?	Yes	No	N/A


QUALITY ORGANIZATION / SYSTEM
Head of Quality Assurance:	Title:
Person to whom they report:	Title:
Number of Inspection Personnel
Ratio of Inspection to Production Personnel
Has your company previously been surveyed by Derco Aerospace, Inc.?	Yes	No
Has there been any significant changes to your organization?	Yes	No
If yes, please describe:


Authorized Person Completing Survey:
Name
Title
Date


* You have chosen to EMAIL your evidence of approval/accreditation documents using our upload application * * You will be directed to the proper page once you click the Submit Button *
* You have chosen to EMAIL your evidence of approval/accreditation documents separately *
*** You have chosen to FAX your evidence of approval/accreditation documents * Please use Fax# 860-998-9129***

Click here to submit this form to Derco Aerospace Quality Assurance

Form QA400-110 Rev 11/14/11