Page 1 NB-244 Rev. 5 (7/13)

QUALIFICATION REVIEW REPORT FOR

ACCREDITATION OF OWNER-USER INSPECTION ORGANIZATIONS

Survey Completion Date: _____________________

Type of Survey: New Renewal Resurvey Provisional

Intended Scope of Activities: Inservice Inspection Only Acceptance Inspection of Repairs & Alterations Both

1. (a) Company Name: _______________________________________________________________ (Including Division, Department, etc., if applicable)

_______________________________________________________________

Physical Address*: ______________________________________________________________ City, State, Postal Code: _________________________________________________________ (b) Mailing Address: _______________________________________________________________ City, State, Postal Code: _________________________________________________________ 2. Schedule of Events (list attendees on a separate Attendance Sheet)

Events Date Times (Start & Stop) Location

Manual Review

Opening Meeting w/Applicant

Manual Review w/ Applicant

Implementation

Exit Meeting w/Applicant

* This is the certificate address and must be a physical location (street and number, road or highway). If a

post office box address is used, it should be shown on line 1. (b).

Page 2 NB-244 Rev. 5 (7/13)

3. MANUAL REVIEW AND IMPLEMENTATION

(a) Manual Review Review the Quality Program Manual against National Board document NB-371, Accreditationof Owner-User Inspection Organizations (OUIO). Indicate on page 3, “Elements of the QualityProgram” if each is: acceptable (YES), deficiencies found and corrected (DFC) or unacceptable (NO). If “DFC” or “NO” is checked, indicate conditions found on Attachment 1, “Summary ofManual Deficiencies and Corrective Actions.”

(b) Implementation of Review Verify that applicant has fully implemented their Quality System. Indicate on Page 3 if each element is: acceptable (YES), deficiencies found and corrected (DFC) or unacceptable (NO). If “DFC” or “NO” is checked, indicate conditions found on Attachment 2, “Summary of Implementation Deficiencies and Corrective Actions.”

4. (a) Recommendation (based on the Survey findings): Issue Certificate of Accreditation Issue Provisional Certificate of Accreditation Resurvey

(b) List any further information which may be important for National Board consideration (including any additional discussion at exit meeting).

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 5. Survey Performed by: Signature: ________________________________ Date: _______________________________ Name Printed: _________________________________________________________________ Affiliation: ____________________________________________________________________

Note: Distribution of this report is limited to: Original to National Board

Copy to applicant

Page 3 NB-244 Rev. 5 (7/13)

ELEMENTS OF THE QUALITY PROGRAM

Notes:

MANUAL REVIEW IMPLEMENTATION

Quality System Requirements YES DFC NO YES DFC NO

General

Organization

Program Description

Document Control

Training

Records

Inspection Methods

Inspection Methods for Repairs (if applicable)

Calibration

Reporting

Control of Contracted Services (if applicable)

Approval

NB-244 Rev. 5 (7/13)

Attachment 1 Page ____ of ____

SUMMARY OF MANUAL DEFICIENCIES AND CORRECTIVE ACTIONS

COMPANY NAME: ___________________________________________________________

LOCATION: _________________________________________________________________

DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED __________________________________ ______________________________ Surveyor Signature Date Note: Use additional pages as necessary

NB-244 Rev. 5 (7/13)

Attachment 2 Page ____ of ____ SUMMARY OF IMPLEMENTATION DEFICIENCIES AND CORRECTIVE ACTIONS

COMPANY NAME: ___________________________________________________________

LOCATION: _________________________________________________________________

DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED DEFICIENCY: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ITEM: OPEN CLOSED __________________________________ ______________________________ Surveyor Signature Date

Note: Use additional pages as necessary