Attachment III Past Performance Questionaire 23R0006 Chemical Portable Toilets 17 Jan 2023.docx

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

Contractor __________________ Contract No.:_______________________________ Subcontract No. (if applicable): ________________________________ POC: ___________________________ Title: ________________________________ (Name) (e.g., PCO/ACO/TM) _____________________________________________________________________ _____________________________________________________________________ (Agency, Telephone No., E-mail Address & Fax Number)

The following questions pertain to the contractor’s record of past (within the past three years) and current performance. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that our information be as factual and accurate as possible. Please provide examples and/or explanations (use additional pages if necessary). The following adjectival ratings shall be used in your response.

Outstanding: Performance meets contractual requirements and exceeds many requirements that benefit the end user. Work was accomplished with few, if any, minor problems for which corrective actions taken by the contractor were highly effective.

Good: Performance meets contractual requirements and exceeds some requirements that benefit the end user. Work was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Acceptable: Performance meets contractual requirements. Work was accomplished with some minor problems for which corrective actions taken by the contractor were satisfactory.

Marginal: Performance does not meet some contractual requirements. Serious problems with contractor performance were experienced for which the contractor has either not yet identified corrective actions, or the corrective actions taken appear only marginally effective.

Unacceptable: Performance does not meet most contractual requirements. Serious problems with contractor performance were experienced for which the corrective actions were ineffective.

PART I: (To be completed by the Offeror)

A. CONTRACT IDENTIFICATION:

Contractor/Company Name/Division:

Address:

Program Identification/Title:

Contract Number:

Contract Type:

Prime Contractor Name (if different from the contractor name cited above):

Contract Award Date:

Forecasted or Actual Contract Completion Date:

Nature of the Contractual Effort or Items Purchased:

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE:

Name: Title: Date:

Telephone Number:

Address:

E-mail Address:

PART II: EVALUATION (To be completed by Point of Contact – Respondent)

A. Compliance of Products, Services, Documents, and Related Deliverables to Specification Requirements and Standards of Good Workmanship:

Outstanding (Explanation must be provided in Comments field below) Good Acceptable Marginal (Explanation must be provided in Comments field below) Unsatisfactory (Explanation must be provided in Comments field below)

Comments:

B. Effectiveness of Project Management (to include use and control of subcontractors):

Outstanding (Explanation must be provided in Comments field below) Good Acceptable

C. Timeliness of Performance for Services and Product Deliverables:

Good Acceptable

D. Effectiveness in Forecasting and Controlling Estimated Costs (Use this Question on Cost Reimbursement Type Contracts Only):

Good Acceptable

E. Commitment to Customer Satisfaction and Business-like Concern for its Customers’ Interest:

Good Acceptable

F. General Comments. Provide any other relevant performance information:

G. Other Information Sources. Please provide the following information:

Are you aware of other relevant past efforts by this company?

If yes, please provide the name and telephone number of a point of contact:

H. Respondent Identification. Please provide the following information:

Organization:

Name:

Title:

Date:

Telephone Number Address:

E-mail Address:

PART III. RETURN INFORMATION

Please return this completed Questionnaire via e-mail to the Contracting Officer identified in the cover letter. Thank you for your assistance.

Signature Date

Typed or Printed Name