70FA4021R00000002 Past Performance Questionnaire (210212-1228).doc

UNCLASSIFIED//FOR OFFICIAL USE ONLY

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

The information that you provide will be used as part of the evaluation to award federal contracts. Therefore, it is important that your information be as factual, accurate, and complete as possible to preclude the need for follow-up by the evaluators. Offerors are to complete Part I of this Questionnaire and forward the Questionnaire to the offeror’s representatives. Offerors are to carbon copy FEMA Office of the Chief Procurement Office’s Contracting Officer Shawn Smith at shawn.smith@fema.dhs.gov and Contract Specialist Sherri Brown at sherri.brown@fema.dhs.gov

NOTE: Offerors are to provide a separate questionnaire for each relevant mission/business critical/comparable/similar project.

PART I. (To be completed by the offeror)

A. CONTRACT IDENTIFICATION

Contractor/Company Name/Division Work Performed For:

Address:

Program/Work Identification/Title:

Company Performed Work Point of Contact:

Company Performed Work Name:

Company Performed Work POC Telephone Number:

Company Performed Work POC Fax Number:

Company Performed Work POC E-mail Address:

Company Performed Work POC Number:

Contract Type:

Prime Contractor Name (if different from the contractor name sited above):

Contract Award Date:

Forecasted and Actual Contract Completion Date:

Forecasted and Actual Contract Award Amount:

Nature of the Contractual Effort or Items Purchased:

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE COMPLETING PART I OF THIS

QUESTIONNAIRE.

Name:

Title:

Date:

Telephone Number:

Fax Number:

Address:

E-mail Address:

PART II EVALUATION (To be completed by the point of contact cited in Part I, Section A – CONTRACT IDENTIFICATION – Government Respondent)

NOTE: If you, as the point of contact, do not have knowledge of or experience with the company in question, please forward Questionnaire to the person who may have the information and notify the Contracting Officer by email at shawn.smith@fema.dhs.gov and the Contract Specialist at sherri.brown@fema.dhs.gov. CO name and contact information.

Please provide your candid responses. [If not applicable to your project put N/A in Comments] A.

Compliance of Products, Services, Documents, and Related Deliverables to Specification Requirements and Standards of Quality.

FORMCHECKBOX

Exceeds Contractual Requirements (Explanation must be provided in comments field below)

FORMCHECKBOX

Meets Contractual Requirements

FORMCHECKBOX

Failed to meet Contractual Requirements (Explanation must be provided in comments field below)

Comments:

B. Effectiveness of Project Management (to include use and control of subcontractors)

FORMCHECKBOX

Exceeds Contractual Requirements (Explanation must be provided in comments field below)

FORMCHECKBOX

Meets Contractual Requirements

FORMCHECKBOX

Failed to meet Contractual Requirements (Explanation must be provided in comments field below)

Comments:

C. Timeliness of Performance for Services and Product Deliverables, including the Administrative aspects of performance.

FORMCHECKBOX

Exceeds Contractual Requirements (Explanation must be provided in comments field below)

FORMCHECKBOX

Meets Contractual Requirements

FORMCHECKBOX

Failed to meet Contractual Requirements (Explanation must be provided in comments field below)

Comments:

D. Effectiveness in Forecasting and Managing Project Cost/Price

FORMCHECKBOX

Exceptional (Explanation must be provided in comments field below)

FORMCHECKBOX

Satisfactory

FORMCHECKBOX

Unsatisfactory (Explanation must be provided in comments field below)

Comments:

E.

Commitment to Customer Satisfaction and Concern for its Customers’ Interest

FORMCHECKBOX

Exceptional (Explanation must be provided in comments field below)

FORMCHECKBOX

Satisfactory

FORMCHECKBOX

Unsatisfactory (Explanation must be provided in comments field below)

Comments:

F. Overall Satisfaction

FORMCHECKBOX

Highly Satisfied (Explanation must be provided in comments field below)

FORMCHECKBOX

Satisfied

FORMCHECKBOX

Not Satisfied (Explanation must be provided in comments field below)

Comments:

G. Given this contractor’s performance, would you choose to contract with them again?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

General Comments: Provide any other relevant performance information

H. Are you aware of other relevant past efforts by this company?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

General Comments: If yes, please provide the name and telephone number of a point of contact:

Respondent Identification – Please provide the following information:

Government Organization:

Address:

Name:

Government Title:

Date:

Telephone Number:

Fax Number:

E-mail Address: