Atch J-5a Past Performance Questionnaire.pdf

CONTROLLED UNCLASSIFIED INFORMATION

When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Attachment J-5a to RFP No. FA520922R0006: Past Performance Questionnaire

CONTROLLED UNCLASSIFIED INFORMATION Page 1 of 5

Section 1: Contract Identification (The offeror shall fill this section)

A. Contractor (Company/Division):

B. Contractor Cage Code:

C. Contract Number:

D. Contract Type: ☐ Firm-Fixed-Price ☐ Fixed-Price Incentive Fee ☐ Cost-Plus-Incentive-Fee

☐ Cost-Plus-Fixed-Fee ☐ Indefinite-Delivery Indefinite-Quantity ☐ Other (Explain):

E. Program / Project Title:

F. Brief Program / Project Description:

G. Program Phase (e.g., Engineering & Manufacturing Development (EMD) / Progress - % (Percent) project work performed (if applicable):

H. Period of Performance

1. Original Schedule:

Beginning Date _________ through ____________

2. Revised Schedule:

Beginning Date _________ through ____________

3. Reason for difference (if applicable):

I. Contract Value (Insert Japanese Yen or U.S. Dollar):

1. Original contract value:

2. Revised contract value:

3. Reasons for difference between original and revised contract value (if applicable):

J. Description of work performed:

K. Was this a competitively awarded contract? ☐ Yes ☐ No

L. Contractor’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Joint Venture

Section 2: Customer or Agency Identification (The offeror shall fill this section)

A. Contracting activity / customer or agency name:

B. Customer or agency description (if applicable):

C. Geographic description of services under this contract:

http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/02.htm#P10_602 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/03.htm#P41_5836

Attachment J-5a to RFP No. FA520922R0006: Past Performance Questionnaire

CONTROLLED UNCLASSIFIED INFORMATION Page 2 of 5

☐ Local ☐ Nationwide ☐ Worldwide ☐ Other Commands (Explain):

Section 3: Respondent Identification (Client shall fill this section)

A. Respondent’s name:

B. Respondent’s title:

C. Respondent’s phone number / fax number / e-mail address:

D. Respondent’s position (e.g., Program Manager, PCO/ACO, etc.):

E. Length of time (number of years/months) respondent worked on subject contract and description of responsibility/position/role:

F. Other suggested points of contact:

Section 4: Performance Information (Client shall fill this section)

In the tables below, indicate your rating for the contractor’s performance by placing an “X” in the appropriate block to the right of each question. Provide supporting information for each response in the space provided.

Attach additional pages if more space is needed. The performance rating scale is defined as follows:

Code Performance Rating

E EXCEPTIONAL – Performance meets contractual requirements and exceeds many requirements to the Government’s benefit. The contractual performance being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

V VERY GOOD – Performance meets contractual requirements and exceeds some requirements to the

Government’s benefit. The contractual performance being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

S SATISFACTORY – Performance meets contractual requirements. The contractual performance being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL – Performance does not meet some contractual requirements. The contractual performance being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

U UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N/A NOT APPLICABLE – Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

Attachment J-5a to RFP No. FA520922R0006: Past Performance Questionnaire

CONTROLLED UNCLASSIFIED INFORMATION Page 3 of 5

Quality Control E V S M U N/A

Q1. Quality of Workmanship; Adequacy of the Contractor Quality

Control (CQC) Plan; Implementation of the CQC Plan; Quality of QC documentation; Adequacy of QC testing (技術や品質管理について評価をしてください)

Q2. Storage of materials (資材の管理について評価をしてください)

Q3. Adequacy of submittals; Adequacy of As-Builts (竣工図や材料承認な

ど、提出物について評価をしてください)

Q4. Use of specified materials (指定材料の使用状況について評価をしてくだ さい)

Q5. Identification/correction of deficient work in a timely manner (欠陥品や問題点に対する解決案・解決方法について評価をしてください)

Q6. Identified problems as they occurred and suggested alternative approaches to problems.

(問題点を速やかに報告して、解決案・解決方法などを提示したか評価をして下

Q7. Provided effective quality control and/or inspection procedures to meet contract requirements.

(契約遂行のために業者の品質管理・検査体制を有効に実行したか評価をして下

Timely Performance E V S M U N/A

T1. Adequacy of initial progress schedule; Adherence to approved schedule; Resolution of delays (工程表の遵守状況や遅延への対応について評価をしてください)

T2. Submission of required documentation (書類回りについて評価をしてください)

T3. Completion of punchlist items

(軽微な修正点への対応について評価をしてください)

T4. Warranty Response (保証期間内の対応について評価をしてください)

T5. Performed multiple concurrent projects with this project. (この契約と 他に同時に契約を遂行したか、ご存知でしたら評価をしてください)

Effectiveness of Management E V S M U N/A

Attachment J-5a to RFP No. FA520922R0006: Past Performance Questionnaire

CONTROLLED UNCLASSIFIED INFORMATION Page 4 of 5

E1. Cooperation and responsiveness; Management of resources/ personnel; Coordination and control of subcontractors; Review/resolution of subcontractor’s implementation of subcontracting plan; Effectiveness of job site supervision; Adequacy of site clean-up; Professional conduct (現場管理について評価をしてください)

E2. Compliance with laws and regulations (規則や法律の遵守状況について評価をしてください)

E3. Home office participated in solving significant local problems.

(問題が有った際に本社が積極的に対応したか評価をして下さい)

E4. Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

(契約を遂行するために経験豊富な管理者や現場監督を配置したか評価をして下

E5. Staff adequately sized and fully qualified in all areas necessary to complete the contract.

(契約を遂行するために充分な数の人工を必要な個所に配置した)

E6. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

(契約期間中、必要に応じた人員の補充、交代を行ったか評価をして下さい)

Compliance with Safety Standards E V S M U N/A

S1. Adequacy of safety plan; Implementation of safety plan; Correction of noted discrepancies (安全対策について評価をしてください）

Cost Performance E V S M U N/A

C1. How accurately did the contractor forecast contract costs?

(契約者の積算/予測した契約金額がいかに正確であったかを評価してください)

C2. How well did the contractor meet forecasted costs and perform within contract costs?

（契約金額の範囲において契約内容は遵守されたか評価してください）

C3. How successfully did the contractor alert the Government/

Contracting Activity of unforeseen costs before they occurred? (不測な

コストが発生する前にそれを米政府/発注者にいかに首尾よく知らされたか評価

してください)

Overall E V S M U N/A

O1. How would you rate the contractor's overall performance on this contract? (この契約における契約者の総合評価をして下さい)

Please discuss each and every response for which you indicated E (exceptional), M (Marginal) or U

(Unsatisfactory) in response to the questions above (use additional sheets, if necessary)

Attachment J-5a to RFP No. FA520922R0006: Past Performance Questionnaire

CONTROLLED UNCLASSIFIED INFORMATION Page 5 of 5

Government Contracts Only: Was this contract partially or completely terminated for default or convenience, or are there any pending terminations?

☐ Yes ☐ Default ☐ Convenience ☐ Pending Terminations ☐ No

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules).

SECTION 5: GENERAL COMMENT

Given what I know today about the contractor’s ability to execute what it promised in its proposal, I

[ click and select an item ] award to it today given that I had a choice.

REMARKS:

Please provide any additional comments concerning this contractor’s performance, as desired.

[click and pick the date]

Respondent’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing Address: 374th Contracting Squadron/PKAA

Attn: Ms. Emi Yasuda / Mr. Kiyotaka

Unit 5228, Building 620, Yokota AB

Fussa-shi, Tokyo 197-0001, Japan

E-Mail to both: Ms. Yasuda at emi.yasuda.jp@us.af.mil and Mr. Kiyotaka at keisuke.kiyotaka.jp@us.af.mil.

http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/03.htm#P41_5836 mailto:emi.yasuda.jp@us.af.mil mailto:keisuke.kiyotaka.jp@us.af.mil