Fillable Printable Household Goods Carrier Evaluation Report
Fillable Printable Household Goods Carrier Evaluation Report
Household Goods Carrier Evaluation Report
HOUSEHOLD GOODS CARRIER EVALUATION REPORT
(For Domestic and International Shipments) (See Privacy Act Statement on reverse)
INSTRUCTIONS
Employee: Complete this form upon delivery of your shipment(s) to your new duty station and then send to your Agency's B/L Issuing Officer or Move
Coordinator for their evaluation.
B/L Issuing Officer/Agency Move Coordinator: After completing the form, send to: General Services Administration (QMCCB), Centralized
Household Goods Traffic Management Program, 1500 East Bannister Road, Building 6, Kansas City, MO 64131 or Fax to (816) 823-3656 or E-mail
EMPLOYEE INFORMATION
NAME
LAST FIRST MI
DUTY STATION
CITY
COUNTRY (If duty station is not in the United States)
STATE ZIP CODE
OLDNEW
TELEPHONE
HHG B/L NUMBER UAB B/L NUMBER
WORK (AREA CODE) WORK (NUMBER)
PICKUP DATE
DELIVERY DATE
WORK (EXTENSION)
POV B/L NUMBER FEDERAL AGENCY ID
CARRIER NAME ON B/L
RELOCATING EMPLOYEE'S RESPONSE (Use "Remarks" on reverse for any comments)
HOW WOULD YOU RATE YOUR SATISFACTION WITH THE
CARRIER?
(Circle or check response)
VERY
UNSATISFIED
SOMEWHAT
UNSATISFIED
NEITHER
SATISFIED NOR
UNSATISFIED
SOMEWHAT
SATISFIED
VERY
SATISFIED
Quality of Packing
Damage to Items
Personal Courtesy of Workers
Delivery/Pickup Within Scheduled Timeframe
Clear Communication of Services Provided
Responsive in Resolving Problems
Overall Quality of Service
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
5
5
5
IF YOU HAVE ANY LOSS OR DAMAGE, WHAT ARE THE ESTIMATED AMOUNTS?
SIGNATURE OF EMPLOYEE DATE
HOUSEHOLD GOODS AIR BAGGAGE VEHICLE
B/L ISSUING OFFICER'S/AGENCY MOVE COORDINATOR'S RESPONSE (Use "Remarks" on reverse for any comments)
HOW WOULD YOU RATE YOUR SATISFACTION WITH THE
CARRIER?
(Circle or check response)
VERY
UNSATISFIED
SOMEWHAT
UNSATISFIED
NEITHER
SATISFIED NOR
UNSATISFIED
SOMEWHAT
SATISFIED
VERY
SATISFIED
Courteous Service When Tracing Shipments
Keeping You Informed of Any Changes Occurring During the
Move
Being Flexible in Meeting Special Employee or Agency Needs
Overall Quality of Service
54321
54321
54321
54321
SIGNATURE OF B/L ISSUING OFFICER/
AGENCY MOVE COORDINATOR
DATE
NAME OF B/L ISSUING OFFICER/AGENCY MOVE COORDINATOR
TELEPHONE NUMBER
AREA CODE NUMBER EXTENSION
GENERAL SERVICES ADMINISTRATION
PREVIOUS EDITION IS NOT USABLE
GSA 3080 (REV. 6/2011)
STANDARD CARRIER ALPHA CODE (SCAC)
REMARKS (Employee and/or B/L Issuing Officer/Agency Move coordinator)
PRIVACY ACT STATEMENT: The information requested on this form is solicited under Title 38, United States Code, and will be used
to monitor and control the carrier's performance. The information may be furnished to the carrier involved for their evaluation. Your
disclosure of this information will aid in our overall mission of making certain transferees received satisfactory performance in the
shipment of their household goods, privately owned vehicle, and air baggage.
GSA 3080 (REV. 6/2011) BACK
