PAST_PERFORMANCE_QUESTIONNAIRE_1645BC-19-Q-00004.docx

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Custom cut polypropylene membrane disc filters Federal contract opportunity
Solicitation number
1645BC-19-Q-00004
Issued by
Department of Labor Mine Safety and Health Administration

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Past Performance Questionnaire

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PAST PERFORMANCE QUESTIONNAIRE

1645BC-19-Q-00004

POLYPROPYLENE MEMBRANE FILTERS

1.The Mine Safety and Health Administration is conducting a proposal evaluation for a solicitation. Under the solicitation, a "Best Value" evaluation will be accomplished. The seller listed in Section A of the attached questionnaire has identified your office as a source to evaluate their past performance and it also authorizes release of this information to our office.
2.The individual most knowledgeable of the contractor's day-to-day operations and overall condition of performance rendered should complete the survey. However, that individual is encouraged to supplement their own knowledge in conjunction with the judgment of others in their organization.
3.The reference shall complete the questionnaire as thoroughly as possible by indicating your ratings and providing comments wherever applicable. For any rating of Unsatisfactory (U) or Marginal (M), we request you provide a narrative and attach it to your response. The narratives need not be lengthy, but should be detailed and descriptive. Use separate evaluation forms for each contract/order being evaluated. Only the attached questionnaire form will be acceptable, not copies of any others.
4.Your time and effort in providing this information is greatly appreciated. The requested information is critical to our evaluation. Please complete and return the completed questionnaire at your earliest convenience, but the document must be received no later than 12:00 PM (EST) on January 11, 2019. Questionnaires shall be e-mailed by the seller’s reference directly to smith.mindy@dol.gov.
5.The identity of individual(s) providing the reference information shall not be disclosed to the seller.
6.If you have any questions, please contact me by e-mail at the address above. Thank you for your cooperation and quick response to this request.

PAST PERFORMANCE EVALUATION QUESTIONNAIRE

1645BC-19-Q-00004

POLYPROPYLENE MEMBRANE FILTERS

SECTION A: Seller Information (to be completed by the seller prior to forwarding to their reference) A. Contractor’s name and address:

B. Point of contact::

C. Phone number (with area code):

D. Contract number:

E. Project title or description of work performed under this project:

F. Contract type:

|_| Firm- Fixed Price |_| Indefinite-Delivery/Indefinite Quantity Task Order |_| Cost-Reimbursement

G. Contract award date:Scheduled completion date:
H. Contract award amount:Current/final project amount:

I. Contractor being evaluated performed as the:

|_| Prime Contractor |_| Subcontractor |_| Supplier on this contract/order J. Authorization is hereby granted to provide the information requested in Section B of this questionnaire.

(Signature)

(Name and title of Authorizing Official) (Date)

SECTION B: Reference Information (to be completed by the seller’s reference) Please note: The identity of individual(s) providing the reference information shall not be disclosed to the seller.

EVALUATED BY:

(Signature) (Date)

Organization:

(Typed or Printed Name)

Address:

(Title)

(E-mail Address) Phone Number:

PERFORMANCE RATING QUESTIONNAIRE

This questionnaire, when completed, shall be treated as Source Selection Sensitive in accordance with FAR 3.104-3 and shall not be disclosed to anyone outside the Government.

The rating definitions are as follows:

U
M
S
V
E
N

Unsatisfactory/ No Confidence Marginal/Little Confidence Satisfactory/ Confidence Very Good/Significant Confidence Exceptional/ High Confidence Neutral/ Unknown Confidence

Based on the Offeror’s performance record, extreme doubt exists that the Offeror will perform the required effort.

Based on the Offeror's performance record, substantial doubt exists that the Offeror will perform the required effort.

Based on the Offeror's performance record, some doubt exists that the Offeror will perform the required effort.

Based on the Offeror's performance record, little doubt exist that the Offeror will perform the required effort.

Based on the Offeror's performance record, essentially no doubt exist that the Offeror will successfully perform the required effort.

No performance record identifiable

1
How efficient was the contractor in abiding by all Rules, Regs, Laws, and Safety Standards?
U
M
S
V
E
N
N/A
2
Were you satisfied with the quality of service performed or items supplied?
U
M
S
V
E
N
N/A
3
How effective were the contractor's quality control and/or inspection procedures?
U
M
S
V
E
N
N/A
4
How well did the contractor perform in a timely manner and schedule?
U
M
S
V
E
N
N/A
5
How well did the contractor resolve Issues/ Problems/Customer Complaints?
U
M
S
V
E
N
N/A
6
Was flexible, cooperative and reasonable in meeting mission requirements, particularly when faced with short-notice mission changes
U
M
S
V
E
N
N/A
7
Paid employees, subcontractors and suppliers in a timely manner
U
M
S
V
E
N
N/A
8
Contractor was able to maintain a good relationship with agency contracting and technical/project management personnel
U
M
S
V
E
N
N/A
9
How likely are you to award another contract to this contractor?

1 = Not at all likely 2 = Some doubts 3 = Somewhat likely 4 = Likely 5 = Very likely

1
2
3
4
5
10
Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes explain outcome in `remarks' section below.
NO
YES

ADDITIONAL REMARKS:

Upon completion of this Performance Rating Questionnaire, the seller’s reference shall forward this questionnaire directly to smith.mindy@dol.gov by January 11, 2019 at 12:00 PM (EST).

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