36C24218Q0060-005.pdf

Diagnostic Medical Physicist Services

Attachment D.4

PAST PERFORMANCE INFORMATION

FOR OFFICIAL USE ONLY

Provide the information requested in this form for each contract/program being described. Provide frank, concise comments regarding your performance on the contracts you identify. Provide a separate completed form for each contract/program submitted. Limit the number of past efforts submitted and the length of each submission to the limitations set forth at Section E.2 (c) (4).

A. Offeror Name (Company/Division) CAGE Code DUNS Number

(NOTE: If the company or division performing this effort is different than the Offeror or the relevance of this effort to the instant acquisition is impacted by any company/corporate organizational change, note those changes. Refer to the "Organizational Structure Change History" you provided as part of your

Present/Past Performance Volume).

B. Program Title

C. Contract Specifics:

1. Contracting Agency or Customer

2. Contract Number/Delivery Order Number

3. Contract Type

4. Period of Performance

5. Original Contract $ Value (Do not include unexercised options)

6. Current Contract $ Value (Do not include unexercised options)

7. Total Contract $ Value (Include unexercised options)

8. If Amounts for 5 and 6 above are different, provide a brief description of the reason

D. Brief Description of Effort

(Please provide a short description of the effort you are citing.)

D. Primary Customer Points of Contact: (For Government contracts provide current information on all three individuals. For commercial contracts, provide points of contact fulfilling these same roles).

Program Manager and/or Site Manager:

OFFICE

NAMES

ADDRESS

TELEPHONE

FAX

EMAIL

Contracting Officer:

OFFICE

NAMES

ADDRESS

TELEPHONE

FAX

EMAIL

Quality Assurance Evaluator:

OFFICE

NAMES

ADDRESS

TELEPHONE

FAX

EMAIL

E. Address any technical (or other) area about this contract/program considered unique.

F. Illustrate how your experience on this program applies to each of the applicable factors under the

Technical Capability and Management Approach sections E.1.1 (c)(2) & E.1.1 (c)(3), respectively.

G. Specify, by name, any key individual(s) who participated in this program and are proposed to support the instant acquisition. Also, indicate their contractual roles for both acquisitions.

H. Include relevant information concerning your compliance with FAR 52.219-8, Utilization of

Small Business Concerns, on the contract you are submitting. Specifically, did this contract include FAR

52.219-8? If so, identify subcontracting goals and the actual percentages achieved. If goals were not met, please explain.

I. Describe the nature or portion of the work on the proposed effort to be performed by the business entity being reported here. Also, estimate the percentage of the total proposed effort to be performed by this entity and whether this entity will be performing as the prime, subcontractor, or a corporate division related to the prime (define relationship).