5. Past Performance Reference Information Form, AA-2026-05.docx

Past Performance Reference Information Form (Completed Form limited to 3 pages per reference contract.)

1. Name and UEI of Offeror Submitting Proposal:

2. Name of Reference Contract Client (e.g., Government Agency or Prime Contractor):

3. Name and UEI of Entity Reference Contract Was Awarded To: (if the Entity was made up of member companies, provide the applicable member company’s name and UEI as well)

5. Reference Contract Number:

Reference Contract Title:

6. Reference Contract Client Point of Contact:

*The reference point of contact must include the Contracting Officer (or equivalent) and may also include the Project Director or Contracting Officer’s Representative (or equivalents).

Name:

Title:

Telephone:

Address:

Email:

7. Reference Contract Period of Performance:

8. Reference Contract Type (e.g., FP, T&M, Cost Re, IDIQ, BPA/BOA, etc.):

9. Reference Contract Total Value and Approximate Average Annual Value

10. Reference Contract Value Performed to Date (Insert the final sum of all invoices, or the sum of all invoices to date, including agreed upon and disputed amounts, paid and awaiting payment; Date = RFP release date):

11. Complexity (Summary Scope, Difficulty of Work, Similarity to this Work Scope, problems encountered and creative solutions with respect to corrective actions taken.

12. Safety statistics: Include information regarding safety record, and the safety record of any proposed lower tier subcontractors, including a communication from its Workers’ Compensation insurance carrier(s) identifying the offeror’s, and any proposed subcontractor’s, (EMR) for each of the last three years, where available. The EMR information may be either state(s) or interstate information, but must be appropriate for the business unit(s) that will perform the work. EMRs from the prime or lower tier subcontractor(s) higher than 1.0 must be explained in the proposal. Offeror must also submit for review, the safety record of any proposed lower tier subcontractors identified post proposal following the same criteria. Comment by Christopher Lockhart: Revise as necessary if not relevant. Could change to QA.

Fully disclose any and all U.S. Occupational Safety and Health Administration (OSHA) citations, California Occupational Safety and Health Administration (Cal-OSHA) citations, and any other state-run occupational safety and health administration citations received by it or any of its proposed lower-tier subcontractors within the past three years, regardless of whether the violation has been contested, appealed, or settled. The disclosure(s) must include a description of the category of violation (i.e., De Minimis, Other-Than-Serious, Serious, Willful, Repeated and/or Failure to Abate Prior Violation), the specifics of the violation and the current status (appealed, abated, resolved, etc.). By submission of an offer, if no such disclosure is submitted, the offeror certifies that neither it nor any of its proposed lower-tier subcontractors have received any OSHA or Cal-OSHA violation citations within the past three years. Failure to disclose any safety violation cited by OSHA or Cal-OSHA within the past three years shall deem the offer non-responsive and/or be cause for Default if discovered after award of a subsequent subcontract resulting from this solicitation.

Note: The Offeror may amend the format for Attachment B, as long as the exact information, font and size and page limitations are followed.