12a - PAST PERFOMANCE EVALUATION.pdf

U.S. COAST GUARD

BASE CLEVELAND, PROCUREMENT & CONTRACTING

BRANCH CONTRACTOR EVALUATION FORM

The U. S. Coast Guard, Base Cleveland, Procurement & Contracting has a requirement for USCG Station Kenosha asbestos abatement. As a result, we are performing a survey and reference investigation on possible contractors for the upcoming contract.

The information contained herein is considered “Source Selection Information” in accordance with FAR 3.104. Therefore, it is asked that you treat it accordingly. While the results of the overall past performance survey may be discussed with the contractor, FAR Part 15.610 and 15.1004 prohibits the release of the name of the individual responding to the survey.

Responses to this questionnaire should be emailed to Sonya Huston at Sonya.J.Huston@uscg.mil

Should you have any questions concerning this survey, please contact the above named person at

(414) 747-7093

I. CONTRACT IDENTIFICATION: (Fill-in)

NAME OF CONTRACTOR BEING RATED: _______________________________________________

CONTRACT NUMBER: _______________________________________________

CONTRACT TYPE: _______________________________________________

PERIOD OF PERFORMANCE: _______________________________________________

TYPE OF SERVICE PROVIDED: _______________________________________________

RESPONDENT’S NAME: PHONE: _______________________________________________

E-Mail FAX: _______________________________________________

RESPONDENT’S COMPANY NAME: _______________________________________________

FOR OFFICIAL USE ONLY

SOURCE SELECTION INFORMATION

SEE FAR 3.104

II. GENERAL GUIDANCE:

The following questions are divided into two types: YES/NO and RATING. When responding to the RATING type questions, choose the number on the scale of 1 to 3, which most accurately describes the contractor’s performance or situation. Responses to the RATING type questions may be supplemented with an explanatory narrative as well. The numbers 1 to 3 correspond with the following descriptive values: Please assign an overall rating for each section where indicated.

Please rate the contractor on a graduated scale from 1 to 3 in accordance with the following descriptive values:

• Excellent (1) - Meets contractual requirements and significantly exceeds contract requirements to the Government’s benefit.

• Satisfactory (2) – Meets contractual requirements.

• Unsatisfactory (3) – Does not meet contractual requirement and is not in the best interest of the

Government.

• IF AN ELEMENT IS NOT APPLICABLE TO YOUR SERVICES, PLEASE RATE AS N/A.

A. QUALITY OF SERVICE: RATING

1. The contractor’s level of effort regarding asbestos abatement met your requirements 1 2 3 N/A

2. The contractor’s initiative at correcting problems or deficiencies prior to Government intervention 1 2 3 N/A

3. The contractor’s response to emergencies 1 2 3 N/A

4. Contractor’s overall quality of service 1 2 3 N/A

5. Has a contract discrepancy report (or equivalent) ever been issued?

YES NO

6. Has an election ever been made to not exercise an option due to contractor’s poor performance?

YES NO

7. OVERALL RATING FOR QUALITY OF SERVICES 1 2 3 N/A

COMMENTS:

B. CUSTOMER SATISFACTION: RATING

1. Rating for customer satisfaction 1 2 3 N/A

2. Ability of the contractor to meet the terms of the contract 1 2 3 N/A

3. OVERALL RATING FOR CUSTOMER SATISFACTION 1 2 3 N/A

C. MANAGEMENT/LABOR: RATING

1. Performance of on-site management staff. 1 2 3 N/A

2. Performance of labor force. 1 2 3 N/A

3. Corporate management’s support of contract performance. 1 2 3 N/A

4. Have there been any labor disputes or violations of the Service Contract Act? YES NO

5. OVERALL RATING FOR MANAGEMENT/LABOR YES NO

D. GENERAL/BUSINESS RELATIONS: RATING

1. Contractor’s preparation and training of personnel. 1 2 3 N/A

2. Contractor’s compliance with contractual terms and conditions. 1 2 3 N/A

3. Contractor’s ability to meet the terms of the contract within the contractually agreed price.

1 2 3 N/A

4. Contractor’s overall cooperation relative to this contract 1 2 3 N/A

5. Have there been any indications that the contractor has had any financial problems?

YES NO

6. Have there been any disputes/claims relative to this contract? YES NO

7. Willingness to award another contract to this contractor. 1 2 3 N/A

8. OVERALL RATING FOR GENERAL/BUSINESS RELATIONS 1 2 3 N/A

ADDITIONAL COMMENTS ON ANY RATING ELEMENT CAN BE MADE BELOW: