Derco QA Supplier Survey

Derco Aerospace Quality Assurance Supplier Evaluation Survey
QA400-110 Rev 05/10/10

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

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

Indicate if business is:	Manufacturer
	Distributor
	FAA Repair
	Other:

Please list types of products or services you supply:


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

	* I will email our evidence of approval/accreditation**
	* I will fax our evidence of approval/accreditation to Fax# 414-371-3435 *

If not accredited, indicate if you are compliant and to what system:


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

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's Certificate of Conformance (CoC) with each shipment contain the following:
Part Number	Yes	No	N/A
Condition of Part	Yes	No	N/A
Derco's Purchase Order Number	Yes	No	N/A
Authorized Signature	Yes	No	N/A
Revision Level	Yes	No	N/A
Name of Manufacturer	Yes	No	N/A
Lot/Batch Numbers	Yes	No	N/A
Cure Date	Yes	No	N/A
Shelf Life Data	Yes	No	N/A

Please answer the following questions:
Do you provide life limited materials shipped with a minimum of 75% life remaining?	Yes	No	N/A
Do you provide pull test data for cables?	Yes	No	N/A
Do you provide pressure test data for hoses?	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 calibration standards traceable to NIST?	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 121, appendix 1, section III, and appendix J, section 1R	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
Do Repairable and Surplus components have certification that the parts have not been involved in an incident/accident which would render them un-airworthy?	Yes	No	N/A

Please answer the following:
Is lot/batch segregation maintained?	Yes	No	N/A
Do you have recall capabilities for non-conforming products?	Yes	No	N/A
Does the system acknowledge the right of a company representative to verify at source that the purchased product conforms to contract requirements?	Yes	No	N/A

Records of traceability are kept for years, and (will be provided / are available for review) when requested. (Please check one option)


PRODUCT LIABILITY
Does your company maintain product liability insurance that covers the products you sell, and for the work and services you perform in an amount not less than Five million US dollars ($5,000,000 USD)?
	Yes
	No

QUALITY ORGANIZATION/SYSTEM
Head of Quality Assurance
Person to whom they report
Number of inspection personnel
Ratio of inspection to production personnel
Have your facilities previously been surveyed by Derco Aerospace, Inc.?
	Yes
	No

Briefly describe and/or attach list of the following:
Production equipment:

Inspection equipment:

Functional test equipment:

Non-destructive test equipment:

Chemical/physical laboratory:

Certification/calibration laboratory:


Authorized Person Completing Survey:
Name
Title
Date

* You have chosen to EMAIL your evidence of approval/accreditation documents * * You will be directed to the proper page once you have submitted your survey *
*** You have chosen to FAX your evidence of approval/accreditation documents * Please use Fax# 414-371-3435 ***

Click here to submit this form to Derco Aerospace Quality Assurance