Free 21322.FH11 - Indiana

REPORT OF VENDOR PERFORMANCE
State Form 21322 (R4 / 4-06)

DEPARTMENT OF ADMINISTRATION PROCUREMENT DIVISION 402 W. Washington St., Rm. W468 Indianapolis, IN 46204

INSTRUCTIONS:

1. Complete this form to report complaints or compliments against vendors, commodities, or to report any unsatisfactory service. 2. Be sure to furnish all necessary detail so that a satisfactory settlement of the complaint can be made. 3. Verify all information to insure accuracy. Vendor performance reports become a permanent record of the commodity or vendor concerned and must be accurate to guarantee intelligent and equitable settlement and to serve as a guide for future action.
Date (month, day, year) Purchase order number Name of buyer Item number Name of vendor contact QPA number

Name of agency Requisition number Name of vendor Address of vendor (number and street, city, state, and ZIP code) Telephone number E-mail address of vendor

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POSITIVE COMMENTS

PROBLEMS WITH DELIVERY AND QUALITY

Vendor confirms delivery time and date prior to delivery. Vendor responds to complaints in a timely manner. Vendor is responsive to our needs. Vendor is reliable and dependable. Other (explain in Remarks section)

Delivery not made on date ordered or promised. Delivery in damaged condition. Quality of commodity is inferior to quality requested. (explain in Remarks section) Unsatisfactory and unauthorized substitute delivered by vendor.

Unsatisfactory workmanship in installation of commodity. Quantity delivered in excess of order and cannot be accepted. Quantity delivered less than ordered. Balance is required. Other (explain in Remarks section)

REMARKS (give detailed explanation of complaint / compliment in this space, using reverse side if additional space is necessary)

Performance Report executed by:
Name (please print) Telephone number Title E-mail address Date (month, day, year)

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Signature