Attachment-5 Past Performance Questionnaire.pdf

“Source Selection Information—See FAR 2.101 and 3.104.”

ATTACHMENT-5

U.S. DEPARTMENT OF HOMELAND SECURITY

U.S. COAST GUARD

SURFACE FORCE LOGISTIC CENTER (SFLC), CPD-1 PBPL

300 EAST MAIN STREET, SUITE 600

NORFOLK, VA 23510-9112

PAST PERFORMANCE QUESTIONNAIRE (PPQ)

I. INSTRUCTIONS

The Company that sent you this questionnaire intends to submit an offer in response to a U.S. Coast Guard solicitation and has identified you as a reference to validate their performance.

Please complete and submit this form to Nancy Brinkman via email to: Nancy.M.Brinkman@uscg.mil before the closing date of the Solicitation. Please check with the Company for specific information.

Completed questionnaires must be received before the closing date of the Solicitation.

This PPQ must be completed by the person most familiar with the contractors’ performance on a present or previous contract and then submitted directly to the U.S. Coast Guard PO by the person completing the

PPQ. **DO NOT send the completed PPQ to the contractor being evaluated.

In addition to this questionnaire, you may receive a follow-up phone call to confirm or clarify information.

The US Coast Guard appreciates for your time, effort, and cooperation in responding to this questionnaire.

Sincerely, Nancy Brinkman

Contracting Officer

DHS/USCG/CPD1/PBPL

Nancy.M.Brinkman@uscg.mil

II. GENERAL INFORMATION

A. PAST PERFORMANCE EVALUATOR & ORGANIZATION/COMPANY INFORMATION

1 Your Name:

2 Your Title:

Your Organization/

Company Name:

4 Address:

5 Your Phone Number:

6 Your Fax Number:

7 Your E-mail Address:

8 Date:

https://www.acquisition.gov/far/current/html/Subpart%202_1.html#wp1145508 https://www.acquisition.gov/far/current/html/Subpart%203_1.html#wp1139280 mailto:Nancy.M.Brinkman@uscg.mil mailto:Nancy.M.Brinkman@uscg.mil

9 Your Signature:

B. CONTRACTOR NAME & CONTRACT IDENTIFICATION

1 Name of Contractor being evaluated:

Type of Instrument (e.g., Contract, Purchase Order, Task Order, Other):

Pricing Type (e.g., Fixed Price, Time &

Material, Cost Reimbursement, Other):

4 Contract or Reference Number:

5 Subcontract Number (if applicable):

6 Order Number (if applicable):

Role of Contractor (Prime or Sub)

(if sub, also provide name of prime)

Description of Service/Supply:

9 Competitive (Y/N):

10 Follow-On (Y/N):

11 Date of Award:

Initial Contract Dollar Value

(w/Options):

13 Final Contract Dollar Value (w/Options):

14 Period of Performance:

15 Place(s) of Performance:

Complexity of Work

(e.g., difficult, routine):

17 If applicable , type and extent of subcontracting:

https://www.acquisition.gov/far/current/html/Subpart%202_1.html#wp1145508 https://www.acquisition.gov/far/current/html/Subpart%203_1.html#wp1139280

III. GENERAL GUIDANCE

Please use the following ratings to score the performance elements below (assessments should reflect only contractor-liable performance):

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

1 = Marginal Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions.

2 = Satisfactory Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

3 = Very Good Performance meets contractual requirements and exceeds some to the

Governments benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

4 = Exceptional Performance meets contractual requirements and exceeds many to the

Governments benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

IV. EVALUATION: Rate the contractor in each of the following Evaluation Areas.

0 1 2 3 4 N/A

1. Quality of Product or Service – please rate

Comments:

2. Schedule - Timeliness of Performance – please rate

0 1 2 3 4 N/A

3. Cost Control – please rate

4. Business Relations – please rate

5 Management of Key Personnel – please rate

6 Utilization of Small Business

Were Subcontractors Used? ____Yes _____No

Comments for Subcontracts

V. SUMMARY

Would your organization/company award another contract to this Contractor (or use the services of the Contractor again)? Yes / No

In summary, if you care to, please give your overall assessment of this Contractor.

Do you have any additional comments to add?