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PAST PERFORMANCE QUESTIONNAIRE

TO BE COMPLETED BY REFERENCED CLIENT: Please return this completed questionnaire via e-mail to Stacy Figlinski, the requesting Contracting Officer at the following email addresses: Stacy.Figlinski@va.gov.

No later than 5 calendar days prior to TOPR closing date. Performance definitions are found on page 4 of this document.

Note: When sending back to Contract Specialist by email – ensure the following: Ensure Email Subject line is as follows: (Solicitation #) , Company Name

Contract Number:

Project Title:

Contract Amount:

Contract Completion Date:

Contractor:

Rating scale is as follows: O=Outstanding, G=Good, S=Satisfactory, M=Marginal, U=Unsatisfactory, N=Neutral The full rating definitions are listed after the questionnaire for reference.

1. Concerning performance, how would you rate the contractor’s adherence to technical requirements of the contract? O G S M U N

COMMENTS/REMARKS:

2. How would you rate the contractor’s performance in completing the project in accordance with planned progress schedule? (Note – Notwithstanding changes that are legitimate to extend performance.

O G S M U N

36C24821R0150 Attachment A

3. How would you rate the contractor’s timeliness of Material Submittals, Payrolls, Quality Control Plan, Safety Plans etc.? O G S M U N

4. How would you rate the contractor submissions of change orders in terms of the number submitted and purpose? O G S M U N

5. How was the Project Management Teams effectiveness? (to include use and control of subcontractors)

6. How was the contractor’s team and rate how well they accomplished the project (to include use and control of subcontractors)

7. Would you hire this contractor again?

Yes No

8. How would you rate the contractor’s OVERALL PERFORMANCE?

Signature of Rater: ____________________________________ Date: ________________

ADJECTIVE RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT

YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE

Adjective Past performance definition

(O) Outstanding The offeror’s performance of previously awarded relevant contracts met contractual requirements and exceeded many to the government’s benefit. The company performed with very few or very minor problems, for which corrective actions taken were, or are expected to be, highly effective. Performance of completed contracts was either consistently of the highest quality or exhibited a trend toward becoming so. The offeror’s past performance record leads to an extremely strong expectation of successful performance.

(G) Good The offeror’s performance of previously awarded relevant contracts met contractual requirements and exceeded some to the government’s benefit. The company performed with some minor problems, for which corrective actions taken were, or are expected to be, effective. Performance of completed contracts was either consistently of high quality or exhibited a trend toward becoming so. The offeror’s past performance record leads to a strong expectation of successful performance.

(S) Satisfactory The offeror’s performance of previously awarded relevant contracts met contractual requirements. The company performed with some problems, for which corrective actions taken by the contractor were, or are expected to be, effective. Performance of completed contracts was consistently of adequate or better quality or exhibited a trend. The offeror’s past performance record leads to an expectation of successful performance.

(M) Marginal The offeror’s performance of previously awarded relevant contracts did not meet some contractual requirements. The contractor’s performance reflected some serious problems, performance reflected some serious problems, for which the contractor either failed to identify or implemented corrective actions in a timely manner, or for which the corrective actions implemented or proposed to be implemented were, or are expected to be, only partially effective. Performance of completed contracts was consistently of mediocre quality or exhibited a trend toward becoming so. The offeror’s past performance record leads to an expectation that successful performance might be difficult to achieve or that it can occur only with increased levels of government management and over sight.

(U) Unsatisfactory

The offeror’s performance of previously awarded relevant contracts did not meet contractual requirements, and recovery, if any, did not occur within the period of performance. The contractor’s performance reflected serious problems for which the offeror either failed to identify or implement corrective actions were mostly ineffective.

Performance of completed contracts was consistently of poor quality or exhibited a trend toward becoming so. The offeror’s past performance will not be achieved or that it can occur only with greatly increased levels of government management and oversight.

(N) Neutral The offeror lacks a record of relevant or available past performance history. Based on this, there is no expectation of either successful or unsuccessful performance.

Fitted N95 No exhalation valve fitted

Surgical Knitted Surgical Mask 3•Layer Knitted Mask

PolyProp 2 Layered polypropylene apron mask

Attachment B

EXPERIENCE INFORMATION SHEET 36C24821Q0974

EXPERIENCE INFORMATION SHEET

PROJECT NO. [ ] Page 1 Must have a total of four (4) projects, more than 4 will not be evaluated; less than 4 may result in a lower rating.

a. Contractor Information of awarded contract (Firm Name, Address, DUNS Number and Cage Code, Phone number, POC Name, POC email, Company email)

b. Contract and/or Task Order Number and Award Date (mm/dd/yyyy)

c. Project Title/Name and Location

d. Work Performed as: Prime Contractor, Subcontractor, Joint Venture, Other (explain)

e. Percent (%) of project work performed by your company

f. If you work as subcontractor, who was the prime?

(Firm Name, Address, DUNS Number and Cage Code, Phone number, POC Name, POC email, Company email)

g. Government Agency/Company which awarded contract to offeror, and Contact Information, such Contracting Officer/Procurement Official/Point of Contract (Name, Title, Email, Phone Number).

Attachment C

PROJECT NO. [ ] Page 2

h. Description of project’s scope of work and the offeror’s specific roles and responsibilities in the project:

Describe work performed in sufficient detail to permit evaluation of project relevancy to this procurement. Detail how work performed is relevant to the effort required by the solicitation? Use continuation sheet for additional information, if necessary

PROJECT NO. [ ] Page 3

i. Describe any difficulties and/or obstacles encountered during performance; steps taken toward resolution

j. Describe unforeseen conditions and how each were resolved

k. Performance Period, including contract start date (mm/dd/yyyy), and original completion date, if not completed, projected date (mm/dd/yyyy) contract start date: original completion date, if not completed, projected completion date (mm/dd/yyyy)

l. Actual Completion Date (mm/dd/yyyy), and if not completed, why?

Actual Completion Date:

If not completed, Why?

m. Project is 50% or more complete? YES [ ] No [ ]. If “No” explain percentage of completion, if not 50% completed for any reason, rating may be lower.

n. The Offerors shall indicate if any of the contracts listed were terminated and the type and reasons for the termination.

o. Original Contract Price (Award Amount), Final Contract Price (to include all modifications, if applicable), Explain Differences.

Original Contract Price: Final Contract Price:

Explain Differences:

Attachment D

Safety or Environmental Violations and Experience Modification Rate

Pre-Award Contractor Safety and Environmental Record Form

Company Name: ______________________________________________

Address: _____________________________________________________

Telephone: ______________________ Fax: ________________________

Email: _______________________________________________________

Contact: ______________________________________________________

1. Utilizing your OSHA 300 Forms, please complete the following information:

Category 2018 2019 2020

Number of man hours (jobsite and office).

Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).

Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).

Number of serious, willful, or repeat violations from OSHA or any EPA violations within the last 3 years. Please attach explanation for any violations.

Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:

http://www.osha.gov/pls/publications/publication.html.

2. Who administers your company’s Safety and Health Program?

3. Company’s Insurance Experience Modification Rate (EMR) for the past 3 years (an EMR of 1 or less is required): _____________

Please see FOPR 36C24821R0073, Part I, paragraph 12 for instructions.

Attachment D http://www.osha.gov/pls/publications/publication.html

Solicitation Attachment

Safety or Environmental Violations and Experience Modification Rate

Solicitation Attachment

Safety or Environmental Violations and Experience Modification Rate

Attachment E

Project Number: Date:

Project Title Project Location Offeror Name Offeror Street Offeror City State Zip

Item Labor Cost Material Cost Total Cost Division 1 $ - $ - $ - Division 2 - - - Division 3 - - - Division 4 - - - Division 5 - - - Division 6 - - - Division 7 - - - Division 8 - - - Division 9 - - - Division 10 - - - Division 11 - - - Division 12 - - - Division 13 - - - Division 14 - - - Division 21 - - -

Description

Project Price Breakdown

Masonry Metals Wood and Plastic

General Requirements Existing Conditions Concrete

Specialties Equipment Furnishings

Thermal & Moisture Protect Doors and Windows Finishes

Special Construction Conveying Equipment Fire Suppression

Division 22 - - - Division 23 - - - Division 26 - - - Division 27 - - - Division 28 - - - Division 31 - - - Division 32 - - - Division 33 - - - Division 34 - - -

Overhead % - Profit % - Bond % -

Plumbing

HVAC

Electrical

Exterior Improvements Utilities Transportation Subtotal

Communications Electronic Safety & Security Earthwork

Total Base Offer Cost

Overhead/Profit Subtotals :

Division Subtotals :

0.00%

Base Offer

"General Decision Number: FL20210208 05/07/2021

Superseded General Decision Number: FL20200208

State: Florida

Construction Type: Building

County: Hillsborough County in Florida.

BUILDING CONSTRUCTION PROJECTS (does not include single family homes or apartments up to and including 4 stories).

Note: Under Executive Order (EO) 13658, an hourly minimum wage of $10.95 for calendar year 2021 applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2015. If this contract is covered by the EO, the contractor must pay all workers in any classification listed on this wage determination at least $10.95 per hour (or the applicable wage rate listed on this wage determination, if it is higher) for all hours spent performing on the contract in calendar year 2021. If this contract is covered by the EO and a classification considered necessary for performance of work on the contract does not appear on this wage determination, the contractor must pay workers in that classification at least the wage rate determined through the conformance process set forth in 29 CFR 5.5(a)(1)(ii) (or the EO minimum wage rate,if it is higher than the conformed wage rate). The EO minimum wage rate will be adjusted annually. Please note that this EO applies to the above-mentioned types of contracts entered into by the federal government that are subject to the Davis-Bacon Act itself, but it does not apply to contracts subject only to the Davis-Bacon Related Acts, including those set forth at 29 CFR 5.1(a)(2)-(60). Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts.

Modification Number Publication Date 0 01/01/2021 1 01/22/2021 2 04/09/2021 3 05/07/2021

ASBE0067-003 01/01/2021

Rates Fringes

ASBESTOS WORKER/HEAT & FROST

INSULATOR........................$ 30.12 13.11

ELEV0074-001 01/01/2021

ELEVATOR MECHANIC................$ 43.95 35.825

FOOTNOTE:

6/8/2021https://sam.gov/wage-determination/FL20210208/3

Attachment F

A. Employer contributions 8% of regular hourly rate to vacation pay credit for employee who has worked in business more than 5 years; Employer contributions 6% of regular hourly rate to vacation pay credit for employee who has worked in business less than 5 years.

Paid Holidays: New Year's Day; Memorial Day; Independence Day; Labor Day; Thanksgiving Day; The Friday after Thanksgiving Day; and Christmas Day.

ENGI0487-021 07/01/2016

OPERATOR: Crane All Cranes 160 Ton Capacity and Over...........$ 33.05 9.20 All Cranes Over 15 Ton Capacity....................$ 32.05 9.20 OPERATOR: Forklift..............$ 23.25 9.20 OPERATOR: Mechanic..............$ 32.05 9.20 OPERATOR: Oiler.................$ 23.50 9.20

IRON0397-007 07/01/2019

IRONWORKER, STRUCTURAL...........$ 30.85 16.47

IRON0397-008 07/01/2019

IRONWORKER, REINFORCING..........$ 30.85 16.47

IRON0402-001 01/01/2019

IRONWORKER, ORNAMENTAL...........$ 23.69 12.70

* PLUM0123-002 05/01/2021

PIPEFITTER (Includes HVAC Pipe and Unit Installation)......$ 25.20 16.49

* PLUM0123-003 05/01/2021

PLUMBER..........................$ 25.20 16.49

SUFL2014-017 08/16/2016

CARPENTER, Includes Drywall

Hanging, Form Work, and Metal Stud Installation (Excludes Carpet and Vinyl Floor Laying)...$ 17.37 3.85

CEMENT MASON/CONCRETE FINISHER...$ 15.69 0.00

ELECTRICIAN, Includes Low Voltage Wiring...................$ 22.48 7.76

FLOOR LAYER: Carpet and Vinyl....$ 17.64 0.00

LABORER: Pipelayer..............$ 14.00 1.40

LABORER: Common or General, Includes Carpenter Tending and Cement Mason Tending.........$ 11.84 1.95

OPERATOR:

Backhoe/Excavator/Trackhoe.......$ 22.07 8.80

OPERATOR: Bulldozer.............$ 15.40 1.90

OPERATOR: Grader/Blade..........$ 18.97 0.00

OPERATOR: Loader................$ 14.00 1.40

OPERATOR: Roller................$ 14.43 4.78

PAINTER: Brush, Roller and Spray............................$ 14.72 2.13

ROOFER...........................$ 19.00 1.17

SHEET METAL WORKER, Includes HVAC Duct Installation...........$ 18.17 4.24

SPRINKLER FITTER (Fire Sprinklers)......................$ 20.70 8.84

TILE SETTER......................$ 18.01 0.00

TRUCK DRIVER: Dump Truck........$ 13.22 2.12

TRUCK DRIVER: Lowboy Truck......$ 14.24 0.00

WELDERS - Receive rate prescribed for craft performing operation to which welding is incidental.

Note: Executive Order (EO) 13706, Establishing Paid Sick Leave for Federal Contractors applies to all contracts subject to the Davis-Bacon Act for which the contract is awarded (and any solicitation was issued) on or after January 1, 2017. If this contract is covered by the EO, the contractor must provide employees with 1 hour of paid sick leave for every 30 hours they work, up to 56 hours of paid sick leave each year.

Employees must be permitted to use paid sick leave for their own illness, injury or other health-related needs, including preventive care; to assist a family member (or person who is like family to the employee) who is ill, injured, or has other health-related needs, including preventive care; or for reasons resulting from, or to assist a family member (or person who is like family to the employee) who is a victim of, domestic violence, sexual assault, or stalking. Additional information on contractor requirements and worker protections under the EO is available at www.dol.gov/whd/govcontracts.

Unlisted classifications needed for work not included within the scope of the classifications listed may be added after award only as provided in the labor standards contract clauses (29CFR 5.5 (a) (1) (ii)).

The body of each wage determination lists the classification and wage rates that have been found to be prevailing for the cited type(s) of construction in the area covered by the wage determination. The classifications are listed in alphabetical order of ""identifiers"" that indicate whether the particular rate is a union rate (current union negotiated rate for local), a survey rate (weighted average rate) or a union average rate (weighted union average rate).

Union Rate Identifiers

A four letter classification abbreviation identifier enclosed in dotted lines beginning with characters other than ""SU"" or ""UAVG"" denotes that the union classification and rate were prevailing for that classification in the survey. Example:

PLUM0198-005 07/01/2014. PLUM is an abbreviation identifier of the union which prevailed in the survey for this classification, which in this example would be Plumbers. 0198 indicates the local union number or district council number where applicable, i.e., Plumbers Local 0198. The next number, 005 in the example, is an internal number used in processing the wage determination. 07/01/2014 is the effective date of the most current negotiated rate, which in this example is July 1, 2014.

Union prevailing wage rates are updated to reflect all rate changes in the collective bargaining agreement (CBA) governing this classification and rate.

Survey Rate Identifiers

Classifications listed under the ""SU"" identifier indicate that no one rate prevailed for this classification in the survey and the published rate is derived by computing a weighted average rate based on all the rates reported in the survey for that classification. As this weighted average rate includes all rates reported in the survey, it may include both union and non-union rates. Example: SULA2012-007 5/13/2014. SU indicates the rates are survey rates based on a weighted average calculation of rates and are not majority rates. LA indicates the State of Louisiana. 2012 is the year of survey on which these classifications and rates are based. The next number, 007 in the example, is an internal number used in producing the wage determination. 5/13/2014 indicates the survey completion date for the classifications and rates under that identifier.

Survey wage rates are not updated and remain in effect until a new survey is conducted.

Union Average Rate Identifiers

Classification(s) listed under the UAVG identifier indicate that no single majority rate prevailed for those classifications; however, 100% of the data reported for the classifications was union data. EXAMPLE: UAVG-OH-0010 08/29/2014. UAVG indicates that the rate is a weighted union average rate. OH indicates the state. The next number, 0010 in the example, is an internal number used in producing the wage determination. 08/29/2014 indicates the survey completion date for the classifications and rates under that identifier.

A UAVG rate will be updated once a year, usually in January of each year, to reflect a weighted average of the current negotiated/CBA rate of the union locals from which the rate is based.

WAGE DETERMINATION APPEALS PROCESS

1.) Has there been an initial decision in the matter? This can be:

* an existing published wage determination

* a survey underlying a wage determination

* a Wage and Hour Division letter setting forth a position on a wage determination matter

* a conformance (additional classification and rate) ruling

On survey related matters, initial contact, including requests for summaries of surveys, should be with the Wage and Hour Regional Office for the area in which the survey was conducted because those Regional Offices have responsibility for the Davis-Bacon survey program. If the response from this initial contact is not satisfactory, then the process described in 2.)

and 3.) should be followed.

With regard to any other matter not yet ripe for the formal process described here, initial contact should be with the Branch of Construction Wage Determinations. Write to:

Branch of Construction Wage Determinations Wage and Hour Division U.S. Department of Labor 200 Constitution Avenue, N.W.

Washington, DC 20210

2.) If the answer to the question in 1.) is yes, then an interested party (those affected by the action) can request review and reconsideration from the Wage and Hour Administrator

(See 29 CFR Part 1.8 and 29 CFR Part 7). Write to:

Wage and Hour Administrator U.S. Department of Labor

The request should be accompanied by a full statement of the interested party's position and by any information (wage payment data, project description, area practice material, etc.) that the requestor considers relevant to the issue.

3.) If the decision of the Administrator is not favorable, an interested party may appeal directly to the Administrative Review Board (formerly the Wage Appeals Board). Write to:

Administrative Review Board U.S. Department of Labor

4.) All decisions by the Administrative Review Board are final.

END OF GENERAL DECISION"

Package 1 Attachments for Incorporate/Integrate Double-Ended Switchgear for Building 38 Project 673-20-104; RFP 36C24821R0150

Attachment A Past Performance Questionnaire Attachment B Mask Specification (PPE) Attachment C Experience Information Sheet Attachment D Contractor Safety and Environmental Record Form Attachment E Project Price Breakdown Attachment F Hillsborough County Wage Determination