Attachment 3 - Past Performance Questionaire_Final.pdf

PAST PERFORMANCE EVALUATION QUESTIONNAIRE

Instructions to Offerors Sending Reference Questionnaire Forms:

Section A shall be completed by the Offeror (the firm requesting the reference) prior to issuing the questionnaires. The Offeror shall send the questionnaires for relevant projects completed in the past three (3) years of the proposal due date to the individuals who will provide the reference. For Government contracts, send to the Contracting Officer or Technical Representative. For commercial references, send to personnel with duties similar to those for Government contracts. It is the responsibility of the Offeror to follow-up and encourage references to submit the questionnaire. The completed questionnaire shall be submitted via e-mail directly from the person providing the reference.

Instructions to Person Providing Reference:

In order to assess potential vendors under the DoD 4th Estate Agencies Employee Assistance Programs & Work-Life

Services requirement, the solicitation requires past performance information with respect to each Offeror. As a reference for work performed by the firm identified in Section “A” of this questionnaire, your candid response will assist in the evaluation process. Please complete Section “B” of the questionnaire as thoroughly as possible.

The questionnaire must be submitted to whs.ncr.ad.mbx.essd-services-branch@mail.mil no later than September

30, 2020, 10:00am Eastern. The subject line in the submission e-mail shall clearly indicate: DoD 4th Estate

Agencies Employee Assistance Programs & Work-Life Services HQ0034-20-R-0210 Past Performance

Questionnaire Submission for <Company Name> and the message shall originate from the referenced government or commercial e-mail system.

In addition to this questionnaire, you may receive a follow-up phone call to confirm or clarify information. This is a major WHS/AD acquisition and your input into this evaluation is greatly appreciated. If you have questions regarding this questionnaire or require assistance, please submit inquiries to whs.ncr.ad.mbx.essd-services-branch@mail.mil.

Sincerely, Andrea Montgomery

Contracting Officer mailto:whs.ncr.ad.mbx.essd-services-branch@mail.mil mailto:whs.ncr.ad.mbx.essd-services-branch@mail.mil mailto:whs.ncr.ad.mbx.essd-services-branch@mail.mil

SECTION A

TO BE COMPLETED BY OFFEROR (THE FIRM REQUESTING THE REFERENCE)

PART I: HQ0034-20-R-0210 DoD 4th Estate Agencies EAP & Work-Life Services

OFFEROR INFORMATION

COMPANY NAME AND DIVISION NAME OF OFFEROR:

OFFEROR ADDRESS:

OFFEROR DUNS:

PART II: PAST PERFORMANCE INFORMATION

TITLE OF PROJECT/CONTRACT NUMBER FOR WHICH REFERENCE IS REQUESTED:

PROCUREMENT VEHICLE (e.g. CONTRACT/ORDER/SUBCONTRACT/OTHER):

TYPE OF CONTRACT (e.g. NEGOTIATED, SEALED BID):

PRICING TYPE: (Check all that apply)

___FP ___FPI ___CPFF ___CPAF ___CPIF ___IDIQ ___BOA

___Requirements ___Labor-Hour ___T&M ___Other (Specify)

DATE OF AWARD:

PERIOD OF PERFORMANCE (INCLUDING OPTIONS):

CONTRACT AMOUNT:

INITIAL CONTRACT DOLLAR VALUE (W/OPTIONS):

FINAL CONTRACT DOLLAR VALUE (W/OPTIONS):

ROLE ON PROJECT:

___PRIME

___SUBCONTRACTOR (EXPLAIN TYPE AND EXTENT OF SUBCONTRACTING, IF

APPLICABLE): OTHER (EXPLAIN)

GENERAL DESCRIPTION OF TYPE OF SERVICES/PRODUCTS REQUIRED UNDER THE CONTRACT:

DESCRIBE COMPLEXITY OF WORK:

SECTION B

TO BE COMPLETED BY EVALUATOR (PERSON PROVIDING REFERENCE)

PART I: REFERENCE INFORMATION

NAME & TITLE:

ORGANIZATION (INCLUDING AGENCYAND/OR COMPANY):

CONTRACT ROLE (e.g. CO, COR, PM):

ADDRESS:

PHONE NUMBER:

FAX NUMBER:

E-MAIL:

PART II: INFORMATION ABOUT PROJECT/CONTRACT FOR WHICH REFERENCE IS REQUESTED

Please identify and correct any information that is not accurate in Section A.

Please objectively assess the requesting firm in each performance element below by assigning an “X” to the most appropriate rating:

Exceptional: Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good: Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Performance Element Exceptional Very Good Satisfactory Marginal Unsatisfactory

1. QUALITY OF PRODUCT OR SERVICE

Assess the contractor’s performance to contract requirements, specifications, and standards of good workmanship (e.g. commonly accepted technical, professional, environmental, or safety and health standards).

Comments:

Performance Element Exceptional Very Good Satisfactory Marginal Unsatisfactory

2. SCHEDULE

Assess the timeliness of the Contractor against the completion of the contract, task orders, milestones, delivery schedules, and administrative requirements (e.g.

efforts that contribute to or affect the schedule).

3. COST CONTROL

Assess the contractor’s effectiveness in forecasting, managing, and controlling cost.*

*Cost Control – not required for Firm Fixed Price (FFP).

If FFP please extend N/A in the comments box.

4. BUSINESS RELATIONS

Assess the integration and coordination of all activities needed to execute the contract, specifically the timeliness, completeness, and quality of problem identification, corrective action plans, proposal submittals, the contractor’s history of reasonable and cooperative behavior (to include timely identification of issues in controversy), customer satisfaction, timely award, and management of subcontractors.

5. MANAGEMENT OF KEY PERSONNEL

Assess the contractor’s performance in selecting, retaining, supporting, and replacing, when necessary, key personnel.

6. UTILIZATION OF SMALL BUSINESS

FAR Subpart 19.7 and 15 U.S.C. 637 contains statutory requirements for complying with the Small

Business subcontracting Program. Assess whether the contractor provided maximum practicable opportunity for small business to participate in contract performance consistent with efficient performance of the contract.*

*Not required for Small Businesses.

7. Comments:

8. Additional comments you would like to share

Signature/Date