36C25622R0067 EXHIBIT A R1.docx

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Source Selection Sensitive Information—See FAR 2.101 & 3.104 Project No. 667-18-119 Upgrade Water Distribution System – Main Hospital 36C25622R0067

EXHIBIT A

PERFORMANCE RELEVANCY SURVEY

Offeror Name/Company

PART 1. CONTRACT REFERENCES: Provide the following information requested in this format for each of the projects/contracts you intend to have considered for evaluation. Projects shall have been completed no more than 5 years prior to the solicitation issue date. Provide all information requested regarding YOUR PERFORMANCE on the contracts you elect to reference.

Project Submittal #___________________ (NOTE: Offerors allowed NO MORE than 5 projects- offerors to make appropriate copies) Project/Contract Title: ________________________________ Contract Number/Task Order Number:_______________________ Location of Project:__________________________________ Description of Effort as Prime ( ) or Subcontractor ( ) Original Contract Value: $________________________ Current/completed Contract Value: $_________________________ Was project completed on time: Yes ( ) No ( ) Start date: ___________________ End date:_________________ Reason for delay if applicable:__________________________________________________ Any liquidated damages: Yes ( ) No ( ) CPARS available: Yes ( ) No ( ) (NOTE: Offeror can provide CPARS with proposal; however, the questionnaire has more detailed questions.)

Provide detailed description of the work performed under the contract and describe why you believe the work is VERY REVELANT, RELEVANT, or SEMI-RELEVANT. (Circle one)

Very Relevant Present/past performance effort involved essentially the same scope and magnitude of effort and complexities this solicitation requires.

Relevant Present/past performance effort involved similar scope and magnitude of effort and complexities this solicitation requires.

Somewhat Relevant Present/past performance effort involved some of the scope and magnitude of effort and complexities this solicitation requires.

Relevance detailed description of project to include work by subcontractors:

Point of Contact of Reference on project (who you are sending questionnaire/survey to):

Name: ________________________ Title: ________________________ Agency: ________________________ Email: ________________________ Phone: ________________________ POTENTIAL OFFERORS: IT IS YOUR RESPONSIBILITY TO FOLLOW-UP WITH YOUR REFERENCES IN SUBMITTING QUESTIONNAIRES PRIOR TO THE CLOSE OF THE SOLICITATION.

PART 2. NOT RELATED TO PART 1: Additional offeror information required, but not project specific. THIS INFORMATION NEED ONLY BE PROVIDED ONCE IN YOUR SUBMISSION PACKAGE.

Offeror representative providing the below information:_______________________

1. Provide information regarding the assessment of liquidated damages on any contracts within the last five years. (Frequency, circumstances, severity of problem, etc.)

2. Offerors are strongly encouraged to include with their proposals information on problems encountered on any relevant projects and the specific corrective actions taken to remedy the problems. Furthermore, please provide explanation of any marginal ratings in CPARS if applicable:

3. Other Past Performance Considerations. Information provided shall be limited to the period starting five years prior to the solicitation release date and may include the following:

a. Professional/Industry awards (Identify award type, date of award and copy of certificate if applicable), Letters of appreciation, recognition or commendations

b. Discuss unique skills and accomplishments (Explain unique skills and/or accomplishments and provide supporting information for verification).

4. Address any technical areas about this project you consider uniquely relevant to this solicitation.

· Descriptions must address the following:

· Describe the specific elements of the work performed by your firm.

· Indicate what elements of work were performed by your major subcontractors and indicate if those same subcontractors will be used on this project.