Past Performance Questionnaire Fillable.pdf

PAST PERFORMANCE QUESTIONAIRE

Please provide your candid responses. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does. Thank you.

PART I. (To be completed by the Quoter)

A. CONTRACT IDENTIFICATION

Name of Contractor/Company being evaluated: ______________________________

Name of Contractor/Company providing the evaluation: ________________________

Address: _____________________________________________________________

Program/Account Identification/Title: _________________________________________

Contract Number: ________________________________________________________

Contract Type: __________________________________________________________

Contract Amount: ________________________________________________________

Prime Contractor Name (if different from the contractor name cited above):

Period of Performance: ___________________________________________________

Contract Award Date: ____________________________________________________

Forecasted or Actual Contract Completion Date: _______________________________

Detailed description of purchases or services provided: __________________________

Was this work with a: Commercial_____ Fed Gov’t_____ Local/State Gov’t_____ entity.

Relevance of the referenced contract to the current requirement:

FOR OFFICIAL USE ONLY / COMPETITION SENSITIVE

SOURCE SELECTION INFORMATION - SEE FAR 2.101 AND 3.104

B. IDENTIFICATION OF QUOTEOR’S REPRESENTATIVE

Name: _____________________________________________________________________

Title: ______________________________________________________________________

Date: ______________________________________________________________________

Telephone Number: __________________________________________________________

Address: ___________________________________________________________________

E-mail Address: _____________________________________________________________

PART II. EVALUATION (TO BE COMPLETED BY POINT OF CONTACT – RESPONDENT)

For each performance element identified below, references should evaluate performance of the firm or individual identified in Part 1 of this form. Where the reference lacks sufficient information to provide an evaluation for a particular performance element, this should be noted. Where any deficiency or unfavorable information is identified, the reference should identify any mitigating factors that may weigh in favor for the person/firm on whose behalf the reference is provided (i.e., problems due to causes outside the contractor’s control). An individual within your organization that is knowledgeable of the contractor’s day-to-day operations and overall performance should complete this questionnaire. However, that individual is encouraged to supplement their own knowledge of the contractor’s performance with the judgment of others within their organization, as applicable.

The following chart depicts the ratings that are to be used to evaluate the contractor’s performance:

O G A U

Outstanding Good Acceptable Unsatisfactory Performance met all contract requirements and exceeded many.

Problems, if any, were negligible, and were resolved in a timely and highly effective manner.

Performance met all contract requirements and exceeded some.

There were few minor problems, which the contractor resolved in a timely, effective manner.

Performance met contract requirements.

There were some minor problems;

corrective actions taken by the contractor were satisfactory.

Performance did not meet contractual requirements.

There were serious problems, and the contractor’s corrective actions were ineffective.

LOW RISK LOW RISK MODERATE RISK HIGH RISK

NOTE: UNKNOWN RISK WOULD BE THE EQUIVALENT TO THE CUSTOMER PROVIDING

A NOT APPLICABLE (N/A) TO ANY OF THE QUESTIONS.

When responding to the questions listed, circle the letter that most accurately describes the contractor’s performance or situation. For any outstanding or unsatisfactory rating, please provide explanatory narratives in the remarks block. These narratives need not be lengthy, just detailed. If a question is not applicable, circle N/A. If you circle a Yes/No answer that is marked with an asterisk (*), please provide a corresponding explanation in the remarks block.

Handwritten responses to this questionnaire are acceptable. However, if responses are handwritten, please print legibly. Your time and effort in providing this vitally important information are greatly appreciated.

PERFORMANCE ELEMENTS:

QUALITY OF SERVICE

1. Contractor’s ability to meet minimum quality standards specified for performance.

2. Contractor’s ability to effectively control the quality of services provided.

3. Contractor’s compliance with contractual terms and conditions.

4. Quality of products/services furnished. O G A U

5. Overall rating of contractor’s standard of workmanship. O G A U

6. Overall rating of contractor’s quality of service. O G A U

TIMELINESS OF SERVICE

1. Contractor’s ability to meet specific response times and scheduled time frames for completion of specific tasks.

2. Contractor’s responsiveness/timeliness for providing administrative reports/documents required by the contract.

3. Contractor’s adherence to delivery schedules? O G A U

4. Contractor’s timeliness in responding to emergency service requirements.

5. Overall rating of contractor’s responsiveness/timeliness. O G A U

BUSINESS RELATIONS

1. Contractor’s ability to identify problems and potential problems, and promptly notify the Contracting Officer.

2. Contractor’s ability to correct problems and prevent or mitigate potential problems in a timely manner.

3. Contractor’s willingness to improve and correct noncompliance issues or concerns.

4. Contractor’s ability to use effective approaches and provide technical expertise and resources to solve contract problems.

O G A U

5. Extent to which the contractor has demonstrated reasonable and cooperative behavior.

6. Contractor’s effectiveness in interfacing with the

Contracting Officer, quality assurance personnel, and customers.

7. Contractor’s flexibility in satisfying the requirements of its customers.

8. Extent to which the contractor provided prompt and courteous service when responding to customer complaints.

9. Contractor’s ability to coordinate, integrate, and provide for effective subcontractor management

10. Overall rating of customer satisfaction. O G A U

11. Overall rating of business relations. O G A U

MANAGEMENT OF KEY PERSONNEL

1. Contractor’s ability to select and retain cooperative and effective key personnel, such as the contract manager and quality control personnel.

2. Extent key personnel were knowledgeable about contractual requirements.

3. Contractor’s ability to meet appropriate staffing levels with qualified personnel in order to provide required services.

4. Rate the contractor’s ability to provide continuity of key personnel on the contract.

5. Rate the contractor’s ability to replace key personnel in a timely fashion

6. Contractor’s ability to effectively manage subcontractors. O G A U

7. Rate the level of the functional expertise of the contractor’s staff.

8. Overall rating of contractor’s management of key personnel.

COMPLIANCE WITH ENVIRONMENTAL, SAFETY,

HEALTH, AND SECURITY REQUIREMENTS

1. Has the contractor ever received any Notices of Violations for noncompliance with environmental laws or regulations?

2. Contractor’s compliance with environmental requirements.

3. Contractor’s compliance with safety requirements. O G A U

4. Contractor’s compliance with health requirements. O G A U

5. Contractor’s compliance with security requirements. O G A U

COST MANAGEMENT

(COST CONTRACTS)

1. Extent to which the contractor provided reliable, supportable cost estimates or quotes

2. Extent to which the contractor met the proposed cost estimates?

CONTRACTUAL CONSIDERATIONS

1. If a subcontracting plan was required, extent to which contractor met applicable goals for small business participation.

2. Has an election ever been made not to exercise an option or continue relations due to contractor’s poor performance?

YES* NO

3. Has a Contract Discrepancy Report ever been issued? YES* NO

4. Has a cure notice or show cause notice ever been issued? YES* NO

5. Has this contract been partially or completely terminated for default or convenience?

YES* NO

Partially ________ Completely _________

6. Are there any pending terminations? YES* NO

7. Overall rating of contractor’s performance under this contract.

8. Would you hire this contractor again? YES NO

*REMARKS

Are you aware of other relevant past efforts by this company?

If yes, please provide the name and telephone number of a point of contact:

Name: _____________________________________________________________________

Title: ______________________________________________________________________

Date: ______________________________________________________________________

Telephone Number: __________________________________________________________

Address: ___________________________________________________________________

E-mail Address: _____________________________________________________________

PART III. RETURN INFORMATION

Please return this completed Questionnaire via e-mail to the Contract Specialist, Priscilla Burke, Priscilla.Burke@va.gov

Thank you for your assistance!

mailto:Priscilla.Burke@va.gov