Atch10_Past Performance Questionnaire.docx

For Official Use Only When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Section 1: Contract Identification

A. Contractor (Company/Division):

B. Contractor Cage Code:

C. Contract Number:

D. Contract Type (e.g., Firm-Fixed-Price (FFP), Fixed-Price-Incentive-Fee (FPIF), Cost-Plus-Incentive-Fee (CPIF), Cost-Plus-Fixed-Fee (CPFF), etc.):

E. Contract Title:

F. Period of Performance

1. Original Schedule (assuming all options exercised):

Beginning Date _________ through ____________

2. Current Schedule (assuming all options exercised):

Beginning Date _________ through ____________

3. Reason for difference (if applicable):

G. Contract Dollar Value (use FY21 budget rate of ¥107.9114 to $1.00 if conversion is necessary)

1. Original maximum contract dollar value (assuming all options exercised): $

2. Current maximum contract dollar value (assuming all options exercised): $

3. Reasons for difference (if applicable):

H Description of work performed:

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

J. Contractor’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Key Personnel

Section 2: Customer or Agency Identification

A. Customer or agency name:

B. Customer or agency description (if applicable):

C. Geographic description of services under this contract (i.e., local, nationwide, worldwide, other Commands):

Section 3: Respondent Identification

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

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.

Q1. Workmanship and quality control.

Q2. Adequacy / Implementation of CQC plan.

Q3. Adequacy of materials.

Q4. Adequacy of submittals, including as-builts.

Q5. Identification / Correction of deficient work in timely manner.

E1. Cooperation and responsiveness.

E2. Management of resources / Personnel.

E3. Coordination and control of subcontractors.

E4. Effectiveness of job-site supervision.

T1. Adequacy of initial progress schedule.

T2. Adherence to approved schedule.

T3. Resolution of Delays.

T4. Submission of required documentation.

C1. Compliance with labor laws and regulations.

C2. Adequacy of Safety Plan.

C3. Implementation of Safety Plan.

O1. Based on the above, what is your overall assessment of the present/past performance for this contractor?

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 he promised in his proposal, I [ definitely would, probably would, might or might not, probably would not, definitely would not ] award to him today given that I had a choice.

REMARKS:

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

Respondent’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing Address:

35th Contracting Squadron Attn: Mr. Takafumi Nosaki Bldg. 656, Misawa Air Base, Hirahata, Misawa-shi, Aomori-ken, Japan 033-0012

FAX: 0176-52-4793 (Attn: Mr. Takafumi Nosaki) Attachment 10 to RFP No. FA520521R0003 Date: 3 Mar 2021