Attachment 4 Past Performance Reference Form.docx

ATTACHMENT 4

PAST PERFORMANCE REFERENCE FORM

Axion BioSystems Maestro Pro Microelectrode Array (MEA) System – Brand Name or Equal Solicitation Number: ______________________________ Quoter/Contractor Name: ______________________________

UEI: ______________________________

1. INSTRUCTIONS TO QUOTERS

The quoter shall provide past performance information for up to three (3) recent and relevant contracts, purchase orders, task orders, or commercial transactions involving laboratory instrumentation, scientific equipment, microelectrode array systems, electrophysiology equipment, or other products and services similar in scope, complexity, and magnitude to this requirement.

The quoter shall complete one Past Performance Reference Form for each reference submitted.

Past performance information may involve contracts or orders performed for:

· Federal Government agencies;

· State or local government agencies;

· Universities or research institutions;

· Hospitals or laboratories;

· Commercial customers; or

· Other organizations with experience receiving comparable products or services from the quoter.

The Government may contact the references provided and may obtain past performance information from other sources, including CPARS, other Government databases, other Federal agencies, commercial customers, and other sources reasonably available to the Government.

Submission of a reference does not limit the Government to consideration of only the information provided by the quoter.

If the quoter has no recent or relevant past performance, the quoter shall indicate this in Section 10 of this form.

2. REFERENCE IDENTIFICATION

Reference Number:

☐ Reference 1 ☐ Reference 2 ☐ Reference 3 Customer/Organization Name:

Customer Type:

☐ Federal Government ☐ State/Local Government ☐ University/Research Institution ☐ Hospital/Laboratory ☐ Commercial Customer ☐ Other: ________________________________________ Contract / Purchase Order / Task Order Number:

Contract/Order Title:

Prime Contractor or Subcontractor:

☐ Prime Contractor ☐ Subcontractor ☐ Commercial Supplier/Vendor If performed as a subcontractor, identify the Prime Contractor:

3. CUSTOMER POINT OF CONTACT

Name:

Title:

Organization:

Telephone Number:

Email Address:

Alternate Point of Contact, if available:

Alternate Telephone/Email:

The quoter is responsible for providing current and accurate point-of-contact information.

4. CONTRACT / ORDER INFORMATION

Contract or Order Value:

Initial Award Value, if different:

Final or Current Value:

Period of Performance:

Start Date: ______________________________ Completion Date: ______________________________ Status:

☐ Completed ☐ Ongoing If ongoing, identify estimated completion date:

Contract Type, if applicable:

☐ Firm-Fixed-Price ☐ Time-and-Materials ☐ Cost-Reimbursement ☐ Commercial Purchase Order ☐ Other: ________________________________________

5. DESCRIPTION OF PRODUCTS AND SERVICES PROVIDED

Provide a concise description of the products, equipment, and services provided under this contract/order.

Include, as applicable:

· Manufacturer and equipment supplied;

· Model or type of laboratory instrumentation;

· Scientific or research application;

· Hardware;

· Software;

· Software licenses;

· Consumables;

· Installation;

· Calibration;

· System validation;

· Training;

· Warranty services;

· Preventive maintenance;

· Technical support; and

· Other associated services.

Contractor Response:

6. RELEVANCE TO THIS REQUIREMENT

Explain how this reference is similar to the FDA requirement for the Microelectrode Array System.

Address the following areas, as applicable.

A. Similarity of Equipment Describe the similarity between the equipment supplied under this reference and the equipment proposed for this solicitation.

B. Similarity of Technical Complexity Describe the technical complexity of the equipment, software, installation, integration, or scientific application.

C. Installation and System Setup Did the referenced requirement include onsite installation, configuration, calibration, or system verification?

☐ Yes ☐ No If yes, describe:

D. User Training Did the referenced requirement include customer/user training?

☐ Yes

If yes, describe the training provided:

E. Software and Licensing Did the referenced requirement include scientific software, analytical software, or software licensing?

☐ Yes

F. Maintenance / Technical Support Did the referenced requirement include warranty support, preventive maintenance, repairs, technical support, or performance assurance services?

☐ Yes

G. Similarity in Dollar Magnitude Explain how the referenced contract/order is similar in dollar magnitude to this requirement.

7. CONTRACT PERFORMANCE INFORMATION

A. Delivery Performance Were all required products delivered within the contractual delivery schedule?

☐ Yes ☐ No ☐ Not Applicable If no, explain the delay, cause, and corrective action:

B. Technical Performance Did the products and services conform to the customer’s technical requirements?

☐ Yes

If no, explain:

C. Installation Performance Was installation completed within the required schedule?

☐ Yes ☐ No

D. Training Performance Was required training completed satisfactorily and within the required schedule?

☐ Yes ☐ No

E. Warranty / Maintenance Performance Were warranty, maintenance, and technical support requirements performed satisfactorily?

☐ Yes ☐ No

8. PERFORMANCE PROBLEMS AND CORRECTIVE ACTIONS

During performance of the referenced contract/order, did any of the following occur?

If any response above is “Yes,” provide a complete explanation of:

1. The issue;

1. The cause;

1. Corrective action taken;

1. Whether the issue was resolved; and

1. Measures implemented to prevent recurrence.

Contractor Explanation:

9. CPARS / FORMAL PERFORMANCE EVALUATION

Was this contract/order evaluated in the Contractor Performance Assessment Reporting System (CPARS) or through another formal customer performance-evaluation system?

☐ Yes ☐ No ☐ Unknown ☐ Not Applicable If yes, provide the following:

Agency/Customer:

Contract Number:

Evaluation Period:

If known, identify the overall performance ratings:

The Government may independently obtain and consider CPARS or other available performance-evaluation information.

10. NO RELEVANT PAST PERFORMANCE

Complete this section only if the quoter does not have recent or relevant past performance to submit.

☐ The quoter has no recent or relevant past performance applicable to this requirement.

Quoter explanation, if desired:

A quoter without a record of relevant past performance, or for whom relevant past-performance information is not reasonably available, will not be evaluated favorably or unfavorably solely because of the absence of relevant past performance.

Under the solicitation’s LPTA evaluation methodology, such a quoter may receive a Neutral past-performance rating.

11. AUTHORIZATION TO CONTACT REFERENCE

The quoter authorizes the U.S. Food and Drug Administration and/or its authorized representatives to contact the customer identified in this form to obtain information concerning the quoter’s performance.

The quoter understands that the Government may consider information provided by the identified reference as well as information obtained independently from Government databases and other reasonable sources.

☐ Yes – Government may contact this reference.

12. CONTRACTOR CERTIFICATION

I certify that the information contained in this Past Performance Reference Form is accurate and complete to the best of my knowledge.

Company Name:

Authorized Representative:

Title:

Signature:

Date:

Telephone Number:

Email Address: