03C23Q0061 Med Supplies PAST PERFORMANCE QUESTIONNAIRE_04242023.docx

U.S. Customs and Border Protection

PAST PERFORMANCE QUESTIONNAIRE

PART ONE: INSTRUCTIONS

The company who has provided you with this form is proposing on a Department of Homeland Security, Bureau of Customs and Border Protection solicitation to provide medical supplies. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important. Your response on this form shall be sent directly to Kirk Hunt, the DHS CBP Contract Specialist. Do not send back to the requesting company or individual. Please provide an honest assessment and return the questionnaire by email to the address shown below: If you have questions, please contact Kirk Hunt via email at: MEDSUPPLIESRFQ2023@cbp.dhs.gov.

PART TWO: GENERAL INFORMATION

1. OFFEROR’S NAME AND ADDRESS 2. CUSTOMER ORGANIZATION

3. CONTRACT/PURCHASE ORDER NUMBER: 4. EVALUATOR

5. CONTRACT VALUE: NAME:

6. CONTRACT AWARD DATE: 7. CONTRACT COMPLETION DATE:

DIFFICULT ROUTINE

PART TWO: GENERAL INFORMATION CONTINUED

10. BRIEF DESCRIPTION OF YOUR CONTRACT REQUIREMENTS:

PART THREE: OFFEROR PERFORMANCE RATING

On the following pages, please summarize the offeror’s performance in each rating factors. Each factor has a set of subfactors with four possible adjectival ratings. Determine the adjectival rating that most nearly represents your experience with this offeror and indicate your assessment by placing an “X” under the appropriate heading. Offeror performance factors are:

Adjectival ratings are defined below and should be used as a reference in assessing performance:

EXCEPTIONAL = Offer’s performance met all contract requirements and exceeded many, to the customer’s benefit. Offeror’s performance has resulted in a high level of efficiency, productivity, and quality. Very little risk anticipated with performance or lack of customer satisfaction.

SATISFACTORY = Offer’s performance met customer expectations or contract requirements. Some potential risk and lack of customer satisfaction is anticipated based upon the offeror’s past performance.

MARGINAL = Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which the contractor’s corrective actions were only marginally effective.

NEUTRAL = No relevant past performance record is available for evaluation.

UNSATISFACTORY = Performance did not meet most (or all) contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.

B

(a) performance of goods and services?

(b) delivery of goods?

(c) delivery of invoices, reports, or other documentation?

C

PART THREE: OFFEROR PERFORMANCE RATING CONTINUED

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

YES Default ______ Convenience NO

If yes, please explain (e.g. inability to meet cost, performance, or delivery schedules - also include contract number, name, address, and phone number of Terminating Contracting Officer - TCO).

2. What was the contractor’s greatest strength in the performance of the contract?

3. What was the contractor’s greatest weakness in the performance of the contract?

4. Was the ordering and delivery process customer-friendly? Please describe.

5. Did the contractor demonstrate business like concern for the customer with regards to any challenges or potential issues that were encountered? Please describe.

6. Would you award another contract to this contractor?

YES No

COMMENTS:

PART FOUR: EVALUATOR’S CERTIFICATION

I HEREBY CERTIFY THAT THE INFORMATION IN THIS FORM IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE OF EVALUATOR

TITLE OF EVALUATOR