Attachment_J.1.doc

ATTACHMENT J.11

PAST PERFORMANCE EVALUATION QUESTIONNAIRE

INSTRUCTIONS TO OFFERORS:

Section A (Parts I and II) shall be completed by the Offeror (the person or entity requesting the evaluation) prior to issuing the questionnaires to the evaluator(s). The Offeror shall send the questionnaires for relevant projects in size, scope and complexity that are in progress or have been completed within the past five (5) years to individuals who will be providing the reference. If using a Government contract for the purposes of this evaluation, the Offeror shall send the questionnaire to the Contracting Officer (CO) or Contracting Officer’s Representative (COR/COTR). If using a Commercial entity, the Offeror shall send the questionnaire to personnel with oversight duties similar to those in Government contracts mentioned above (e.g. security specialist, Contracts Manager, Program Manager, COR, COTR, etc.). It is the responsibility of the Offeror to follow-up and to encourage references to submit the questionnaire in a timely manner. The completed questionnaire shall be submitted via e-mail directly from the person providing the reference.

INSTRUCTIONS TO PERSON, OR ENTITY, PROVIDING REFERENCE:

In order to appraise potential vendors under this solicitation, the HHS contracting office is obtaining past performance information regarding the quality of the Offeror’s past performance relative to a contract, completed or in progress, at your company/agency. As a reference for work performed by the company/entity identified in Section A of this questionnaire, your candid response will assist in the evaluation process. Please complete Section B (Parts I and II) of the questionnaire as thoroughly as possible, in the electronic version (please do not print the document out and write in your answers/ratings). The Past Performance Questionnaires must be submitted to Kristine Zechman at Kristine.Zechman@psc.hhs.gov no later than TBD. The subject line of the submission e-mail should clearly indicate: CPSC Consumer Feedback and Comprehension Studies - Past Performance Questionnaire Submission.

In addition to this questionnaire, you may receive a follow-up phone call or email to confirm or clarify information. Your input into this evaluation is greatly appreciated! If you have questions regarding this questionnaire or require any assistance, please submit inquiries to Kristine Zechman.

SECTION A

To be completed by THE OFFEROR

PART I: OFFEROR INFORMATION

COMPANY NAME AND DIVISION NAME:

OFFEROR ADDRESS:

OFFEROR DUNS number:

PART II: PAST PERFORMANCE INFORMATION

TITLE OF PROJECT/CONTRACT NUMBER FOR WHICH REFERENCE IS REQUESTED:

PROCUREMENT VEHICLE (e.g. CONTRACT/ORDER/SUBCONTRACT/OTHER):

TYPE OF CONTRACT (e.g. NEGOTIATED, SEALED BID):

PRICING TYPE: (Check all that apply)

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FP FORMCHECKBOX

FP-EAP FORMCHECKBOX

CPFF-Completion FORMCHECKBOX CPFF-Term FORMCHECKBOX

CPIF FORMCHECKBOX

CPAF FORMCHECKBOX

ID/IA FORMCHECKBOX

BOA

Requirements FORMCHECKBOX Labor-Hour FORMCHECKBOX

T&M FORMCHECKBOX

CR FORMCHECKBOX

Other (Specify):_________

DATE OF AWARD:

PERIOD OF PERFORMANCE (INCLUDING OPTIONS):

CONTRACT AMOUNT:

· INITIAL CONTRACT DOLLAR VALUE (W/OPTIONS): _________________

· FINAL CONTRACT DOLLAR VALUE (W/EXERCISED OPTIONS): _________________

OFFEROR ROLE ON PROJECT:

PRIME

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SUBCONTRACTOR (EXPLAIN TYPE AND EXTENT OF SUBCONTRACTING, IF APPLICABLE):

OTHER (EXPLAIN):

BRIEF DESCRIPTION OF TYPE OF SERVICES/PRODUCTS REQUIRED UNDER THE CONTRACT:

DESCRIBE SIZE, SCOPE, AND COMPLEXITY OF CONTRACT:

SECTION B

TO BE COMPLETED BY THE EVALUATOR (PERSON OR ENTITY PROVIDING REFERENCE)

PART I: REFERENCE INFORMATION

NAME & TITLE:

ORGANIZATION (INCLUDING AGENCYAND/OR COMPANY):

CONTRACT ROLE (e.g. CO, COTR, PM):

ADDRESS:

PHONE NUMBER:

E-MAIL:

PART II: INFORMATION ABOUT PROJECT/CONTRACT FOR WHICH REFERENCE IS REQUESTED

NOTE: Please identify and correct any information that you believe to be inaccurate in Section A:

Please objectively assess the requesting firm in each performance element below by assigning an “X” to the most appropriate rating:

· EXCELLENT (Based on the Offeror’s record of Past Performance, no issues, concerns, or risks are associated with receiving quality products, timely services and full contract performance.)

· GOOD (Based on the Offeror’s record of Past Performance, there is very little risk associated with receiving quality products, timely services and full contract performance.)

· FAIR (Based on the Offeror’s record of Past Performance, there is some risk associated with receiving quality products, timely services and full contract performance.)

· UNSATISFACTORY (Based on the Offeror’s record of Past Performance, there is substantial risk associated with receiving quality products, timely services and full contract performance.)

1. QUALITY OF PRODUCT OR SERVICE

Assess the contractor’s performance to contract requirements, specifications, and standards of good workmanship (e.g. commonly accepted technical, professional, environmental, or safety and health standards).

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2. SCHEDULE

Assess the timeliness of the Contractor against the completion of the contract, task orders, milestones, delivery schedules, and administrative requirements (e.g. efforts that contribute to or effect the schedule variance).

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3. COST CONTROL

Assess the contractor’s effectiveness in forecasting, managing, and controlling cost.*

*Cost Control – not required for Firm Fixed Price or Firm Fixed Price with economic adjustment.

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4. BUSINESS RELATIONS

Assess the integration and coordination of all activities needed to execute the contract, specifically the timeliness, completeness and quality of problem identification, corrective action plans, proposal submittals, the contractor’s history of reasonable and cooperative behavior (to include timely identification of issues in controversy), customer satisfaction, timely award and management of subcontractors.

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5. MANAGEMENT OF KEY PERSONNEL

Assess the contractor’s performance in selecting, retaining, supporting, and replacing, when necessary, key personnel.

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6. MANAGEMENT OF TEAMS AND/OR SUBCONTRACTORS & ABILITY TO WORK WITH OTHER CONTRACTOR STAFF Assess how the contractor interacted with its prime/subcontractors on the effort, and, if applicable, how the contractor interacted with the staff of other contractors with whom they came into contact.

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FOR #7, PLEASE CHECK “Yes” or “No”, as appropriate:____________________

7. Given the choice, would you do business with this contractor again?

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YES

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NO

8. Additional comments to further explain any of the aforementioned ratings:

<Type Your Name here>__

Signature

DATE:

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