PAST_PERFORMANCE_QUESTIONNAIRE.pdf

Source Selection Information – See FAR 3.104 and FAR 2.101

PAST PERFORMANCE QUESTIONNAIRE

The Department of Homeland Security (DHS), FEMA, recently released a Request for proposal for the procurement of supplies or services RFP #70FB8018R00000016. Offerors were asked to provide information on contracts similar in nature, size and complexity to the present requirement on which they had performed in the past. An Offeror has submitted this to you as a reference for past performance. (See blocks 1 to 3 below).

We need your opinion on how well the contractor performed on your contract(s). Please fill out the attached questionnaire and send it electronically to either the Contracting Officer at Rahsaan.Edwards@fema.dhs.gov or the Contract Specialist at

Thelma.Fields@fema.dhs.gov. To be considered, this form must be filled out and received by the contracting officer no later than the closing date and time listed in the request for proposal. DHS/FEMA may contact you to clarify or verify any information provided. For purposes of confidentiality, only send this completed form to the FEMA contracting officer.

Your input will be confidential. Please note your comments will be used to form the basis for evaluation of this Offeror.

Thank you in advance for your assistance. If you have any questions please contact the Contracting Officer at

Rahsaan.Edwards@fema.dhs.gov.

A. CERTIFICATION

By law, the Government will not disclose the names of individuals providing reference information during discussions with the contractor identified in Block 1 below.

Block 1. Contractor Name:

Block 2. Contractor phone number and address:

Block 3. Contract Name and Number: |

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS QUESTIONNAIRE IS ACCURATE AND

COMPLETE TO THE BEST OF MY KNOWLEDGE.

Evaluator’s Printed Name Title

Evaluator’s Mailing Address (Agency, Bldg/Room, Street, City, State, and Zip)

Evaluator’s Signature Date Phone Fax mailto:Rahsaan.Edwards@fema.dhs.gov mailto:Rahsaan.Edwards@fema.dhs.gov

B. INSTRUCTIONS

Two forms are provided to document your opinion: 1) Performance Rating Form; and 2) Supplemental Comment Form.

Please fill out both forms in accordance with the instructions provided on each. Please use the following standards in arriving at your rating: 1) Superior – the contractor’s overall performance was superior. Satisfactory – the contractor’s overall performance was successful but with some minor exceptions 2) Unsatisfactory – the contractor’s overall performance was unsatisfactory

PERFORMANCE RATING FORM (put an X in the appropriate box)

Performance Element Superior Satisfactory Unsatisfactory Not Applicable

1. QUALITY OF

PRODUCT/SERVICES: The contractor provided high quality products and/or services.

2. COMMUNICATION: The contractor worked and communicated well with client management and contracting officials.

3. TIMELINESS OF

PERFORMANCE: The contractor made deliveries on time or sooner than agreed.

4. CUSTOMER SATISFACTION:

The contractor exhibited a commitment to customer satisfaction and achieved customer satisfaction.

5. RESPONSIVENESS AND

ATTENTIVESNESS: The contractor was responsive to client changes, criticism/rejection of contract deliverables and in detecting and correcting errors, poor performance, and other problems.

OVERALL PERFORMANCE::

YES NO

6. Given the choice would you do business with this contractor again?

Supplemental Comment Form

Please provide any additional comments regarding your performance element ratings in the appropriate spaces below.

We appreciate your time and valuable comments.

Performance Element #1, Quality of Product/Services:

Performance Element #2, Communication:

Performance Element #3, Timeliness of Performance:

Performance Element #4, Customer Satisfaction:

Performance Element #5, Responsiveness and Attentiveness: