Attachment 4 Past Performance Survey 3.18.24.docx

PROCUREMENT SENSITIVE WHEN COMPLETED

FOR OFFICIAL USE ONLY

SIR/RFO No. 6973GH-24-R-00101 Occupational and Medical Consultant Service

PAST PERFORMANCE SURVEY

To: _______________________________________________________________________

Organization:_____________________________________________________________

Fax No.: _________________________ E-mail Address:_________________________

Date: __________________________ Number of Pages (including this sheet): 4 in total

Your name was provided as a past performance point of contract for the following:

Contractor Name:_________________________________________________________

Contract Number: _______________________________ Date(s)____________________

Project Title: ___________________________________________________________

Contractor Role / Responsibility (circle one): Prime Contractor Sub-Contractor

In regard to the above contractor’s performance on the referenced contract, please complete the attached Past Performance Questionnaire and return as follows:

Send to: Andre Casiano, Contracting Officer

E-mail Address: andre.casiano@faa.gov

For questions, please send to the above referenced email

Please provide your response no later than April 26, 2023 at 4:00 p.m. Central Time

Thank you!

A. Please complete and/or verify the following reference check information:

1. Name of Contractor: ____________________________________________________

2. Describe of this contract is similar/same to the scope required under SIR 6973GH-23-R-00015

3. Type of contract/agreement for pricing; e.g., firm fixed-price, fixed rate per hour (labor-hour, T&M), cost-reimbursable:

4. Contract Number: _________________________________

5. Total Contract Amount: $____________________________

6. Date of Contract Award: ____________________________

7. Contract Period of Performance: Start _________________ Complete_____________

B. Please complete and/or verify the following responder information:

Name of Responding Point of Contact: _____________________________________________________

Agency/Organization: _________________________________________________________________

Mailing Address: __________________________________________________________

Telephone Number: __________________________________

E-mail Address: __________________________________

1. How would you rate the contractor's overall compliance with contract requirements?

( ) Acceptable ( ) Unacceptable

2. How would you rate the timeliness of the Contractor - adhering to the required schedule?

( ) Acceptable ( ) Unacceptable `

3. Has this contract been partially or completely terminated for default, or is a termination pending?

( ) Yes / If yes, please explain and indicate the status.

( ) No/Acceptable

4. Has it ever been necessary to send this Contractor a Notice to Cure letter?

( ) Yes If yes, please explain and indicate the status.

( ) No

5. How would you rate the performance of the contractor's key personnel?

( ) Acceptable ( ) Unacceptable

6. Would you recommend awarding similar contracts or using the offeror again for future work?

( ) Yes/Acceptable ( ) No/Unacceptable

7. Did you experience any integrity problems with this Contractor?

( ) Yes If yes, please explain.

( ) No

8. Please provide any other comments you may have.

Attachment 4