Attachment 2 - PAST PERFORMANCE QUESTIONNAIRE.docx

PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

SOURCE SELECTION INFORMATION

To: Government agency or commercial organization with knowledge on the Offeror’s past performance.

1. Please complete this questionnaire, which concerns the past performance of a contractor or subcontractor who is doing business (or has done business) with you and is interested in doing business with the Peace Corps. Handwritten responses are sufficient. If you require more space than is provided, please attach additional pages.

2. Responses will be treated as confidential and will be used only by source selection officials in evaluating the offeror’s submitted documents for the contract.

3. Once complete the past performance questionnaire may be returned via email to the following:

4. The following information is required for the past performance questionnaire to be considered. The past performance questionnaire will not be considered if the Government is unable to determine whose past performance or Offeror team to which the past performance belongs.

Contractor/Subcontractor Name:

Customer:

Customer Address:

Primary Point of Contact Name/Title:

Primary Point of Contact Phone Number:

Alternate Point of Contract Name/Title:

Alternate Point of Contract Phone Number:

Contract Number:

Contract Period of Performance (From/To):

Base year Contract Value:

Total Contract Value including any options:

Number of Beneficiaries/Enrollees Served:

Annual Number of Claims Processed (if applicable):

Contract Type:

Contract Summary of Services Provided:

5. Please provide your responses to the questions below. Questions 1-5 pertain to the contractor’s performance in relation to the stated terms of the contract (contract requirements, timeliness, standards, etc.). Questions 6-9 pertain to the manner in which the work was performed (responsiveness, attitude, staff knowledge/skills/abilities, etc.), regardless of how the contractor performed in relation to the terms of the contract. Please use the space following each question to provide additional details or information.

If there are any questions regarding the responses provided, source selection officials will attempt to contact the Primary or Alternate Points of Contact identified above.

Explanation of Codes:

5. Using the codes above, place an “X” next to the appropriate code (letter) for each item on the questionnaire and provide comments (e.g. summarize examples of performance indicated; explain why/how the contractor exceeded requirements were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.).

Assessment Elements

(1) Performance: Rate the contractor's ability to successfully comply with the contract requirements, statement of work, subcontracting plan, etc.

( ) E ( )V ( )S ( )M ( )U ( )N

(2) Schedule adherence: How well did the contractor adhere to the contractual delivery schedule? Were data deliverables and reports submitted on time?

( ) E ( )V ( )S ( )M ( )U ( )N

(3) Quality: How well did the contractor adhere to the Quality Assurance Plan or Performance Base Contracting Requirements? Did the services provided meet the required level of quality or results?

( ) E ( )V ( )S ( )M ( )U ( )N

(4) Business Relations: Did the contractor exhibit reasonable/cooperative behavior in dealing with problems? Was turnover of personnel frequent? Rate the contractor's responsiveness to managing changes and in providing replacement personnel.

( ) E ( )V ( )S ( )M ( )U ( )N

(5) What is your overall rating of the contractor's performance?

( ) E ( )V ( )S ( )M ( )U ( )N

6. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the knowledge, skills and abilities of the contractor’s staff and summarize some examples below.

Comments (e.g., summarize examples of the staff’s knowledge, skills and abilities):

7. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the contractor’s ability to satisfy customers and summarize some examples below.

Comments (e.g., summarize examples of customer satisfaction):

8. In regard to the transition-in phase of this contract please answer the following questions:

1) Did the contractor meet the transition phase-in requirement in a timely matter (in accordance with the agreed transition plan or contractual requirement)? If not, what problems caused a delay?

2) Did the contractor accomplish the connectivity of the information systems, customer websites, etc., in a timely manner? Please explain if there were any problems and how they were resolved.

9. If you had an opportunity to do so, would you do business with this contractor in the future?

(__) Yes (__) No

If no, explain why not:

10. Additional Comments:

Questionnaire completed by:

Name:

Title:

Signature: