36C26118Q0096-009.pdf

PAST PERFORMANCE QUESTIONNAIRE

1. GENERAL INFORMATION: (Contractor to be evaluated)

Name of Contractor:

Contract#: Dollar Amount:

Dates of Performance:

Contractor Performed as: Prime Contractor Sub-Contractor Key Personnel

Brief description of work provided by the Contractor to your organization:

2. RESPONDENT INFORMATION: (person who has knowledge of Contractor’s performance)

Name of Agency or Organization:

Point of Contact: Title:

Office Phone: E-mail:

3. Please answer the following questions using the legend below.

Please evaluate the past performance using only the following ratings without variation. If the rating is

Excellent, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Performance greatly exceeded the contract requirements

“G” = Good = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirements

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, M, or U rating please provide a short summary explanation of rating.

Please rate and provide information/comments for the following: Circle one

Q1. To what extent did the contractor comply with overall contract requirements?

E G S M U

Q2. How successful was the Contractor in filling all required case management, housing placement, and/or supportive services requirements?

Q3. How would you rate the quality provided by this Contractor in terms of technical competence, reliability, and demeanor with your agency staff.

Q4. To what extent was the Contractor able to meet unexpected and short notice referrals and admissions?

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete intake/admissions paperwork, reports, billing and invoicing processes, and overall contract management?

Q6. Did you issue any cure notices, show cause letters, letters of concern, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator

Date

4. PERFORMANCE INFORMATION: Choose the appropriate adjectival rating that most accurately describes the contractor’s performance.

Excellent Performance exceeded many contractual requirements to the government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

An Excellent rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the

Government/Owner. A singular benefit, however, could be of such magnitude that it alone constitutes an

Exceptional rating. Also, there should have been NO significant weaknesses identified.

Good Performance exceeded some contractual requirements to the government’s benefit.

The contractual performance of the element or sub-element being assess was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were effective.

A Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the

Government/Owner. There should have been no significant weaknesses identified.

Satisfactory Performance met contractual requirements.

The contractual performance of the element or sub-element being assess was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were satisfactory.

A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. Per DOD policy, a fundamental principle of assigning ratings is that contractors will not be assessed a rating lower than Satisfactory solely for not performing beyond the requirements of the contract.

Marginal Performance did not meet some contractual requirements. The contractual performance of the element or sub-elements being assessed reflects a serious problem for which the contractor has not yet identified

A Marginal is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the

Government/Owner.

corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory Performance did not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions were ineffective.

An Unsatisfactory rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the

Government/Owner. A singular problem, however, could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

Neutral/ Not

Applicable or

Unknown

No performance record identifiable within the area of evaluation.

Performance was not observed or not applicable to the current effort being reported.