Past_Performance_Questionnaire.docx

PAST PERFORMANCE REFERENCE QUESTIONNAIRE

Item

Requested Information

Information Provided by Reference

A.

Contractor Name

Contractor Address

B.

Contract Number

Task Order Number

Prime/Subcontractor

[ ] Prime [ ] Subcontractor

If Subcontractor, Prime Contractor Name

C.

Contract Type

[ ] Competitive [ ] Sole Source

[ ] IDIQ Task Order [ ] Other

[ ] Fixed Price or Fixed Unit Price [ ] T&M or Cost Reimbursement

D.

Task Order Type

[ ] Fixed Price (Lump Sum) [ ] T&M or Cost Reimbursement

E.

Initial Performance Dates

From: To:

Extensions

From: To:

F.

Initial Costs

Extensions

Total

G.

Work Complexity

[ ] Difficult [ ] Routine

H.

Contract/Order Canceled Prior to Scheduled Completion Date?

[ ] Yes [ ] No

I.

Brief Description of System(s)/ User Environment/ Work (Attach additional pages as necessary)

J.

Reference Organization / Agency Name

K.

Reference Organization Work Functions

L.

Services Geographic Area

[ ] Local [ ] County [ ] State [ ] National

Number of Locations

M.

Reference Giver - Name

Title

Address

Telephone

Fax

Role in acquisition process

Extent of contact with vendor personnel (e.g.

daily, weekly, etc.)

N.

Reference Questions

See Attached Table

O.

Comments (Attach additional pages as necessary)

P.

DOT Reference Taker - Name

Contact Date (If taken over the Telephone)

Evaluator: Vendor: Date Page 1

CUSTOMER SATISFACTION SURVEY

Item

How do you rate the Vendor’s...?

Rating

Comments ability to stay within budget?

ability to stay within schedule?

reporting timeliness & accuracy?

timely and accurate tracking of problems?

timely & accurate answers to technical questions?

ability to resolve system operations performance problems?

ability to adapt to changes in staffing levels?

display of initiative in meeting requirements?

staff’s skills in performing their duties?

responsiveness & promptness to changes in technical direction?

interpersonal relationships with client management & staff?

overall work quality?

overall performance timeliness?

overall management effectiveness?

Evaluator Ratings: (E) Excellent ___ (VG) Very Good ___ (S) Satisfactory ____

(P) Poor ___

Evaluator: Vendor: Page 3