6_Exhibit_X_Past_Performance_Survey_General_Alt1.pdf

Exhibit X Past Performance Questionnaire/Customer Satisfaction Survey

PAST PERFORMANCE QUESTIONNAIRE

1. Contractor Name: 2. Contract Number:

3. Contractor Address: 4a. Contract Type: __Firm Fixed Price ____Cost Reimbursement ___ Other (Please Specify)

4b. Delivery Method: ___ Design Bid Build

____ Design Build ___ Other

5. Agency Name: 6. Agency POC/Phone/email:

7. Period of Performance: Completion Date:

8. Dollar Amount of Award: $ Total Dollar Value with Mods:

9. Title of Contract:

10. Description of Contract Service:

Note: State relevancy to project

11. Complexity of Work: Difficult: ____________ Routine: ____________

NOTE: Please use adjectival ratings from attached sheet.

12. Evaluation Factor 13. Comments (Attach additional sheets, if necessary.) 14. Rating

a. Quality of Work

b. Schedule

c. Cost/Budget Control

d. Management/Business Relations

e. Customer Satisfaction

15. Would you select this firm again? Please explain. (Attach additional sheet if necessary.)

16. Name & Date:

17. Title:

PAST PERFORMANCE RATING GUIDELINES

Summarize Contractor Performance in each of the rating areas. Assign each area a rating of Unsatisfactory, Poor, Fair, Good, Excellent, and Outstanding. Use the following instructions as guidance in making these evaluations.

Note: There is no corresponding guidance for “Customer Satisfaction”. Please use the comments area on the preceding form to justify the rating given “Customer Satisfaction.”

Ratings Quality of Work/

Personnel/Service

-Compliance w/contract requirements -Accuracy of reports -Appropriateness of personnel -Technical excellence

Cost Control

-Within budget -Current, accurate, complete billings -Relationship of negotiated costs to actuals -Cost efficiencies -Change orders issued

Timeliness of Performance

-Met interim milestones -Reliable -Responsive to technical direction -Completed on time

Business Relations/Sub Contractor Mgmt

-Effective Mgmt -Businesslike correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/cooperative -Flexible -Pro-active -Effective SB/SDB Subcontract Program

Unsatisfactory Nonconformances are jeopardizing the achievement of contract requirements.

Cost issues are jeopardizing performance

Delays are jeopardizing achievement of contract reqmts

Responses to inquires/technical, service, administrative issues is not effective.

Poor Overall compliance requires major agency resources to ensure achievement of contract requirements.

Cost issues require major agency resources to ensure achievement of contract rqmnts

Delays require major agency resources to ensure achievement of contract rqmnts

Responses to inquires/technical, service, administrative issues is marginally effective.

Fair Overall compliance requires minor agency resources to ensure achievement of contract requirements.

Cost issues require minor agency resources to ensure achievement of contract remits

Delays require minor agency resources to ensure achievement of contract remits

Responses to inquires/technical, service, administrative issues is somewhat effective.

Good There are no or very minimal quality problems and contractor has met requirements.

Cost issues do not impact achievement of contract remits

Delays do not impact achievement of contract remits

Responses to inquires/technical, service, administrative issues is consistently effective.

Excellent There are no quality issues and contractor has exceeded the contract requirements without commensurate additional costs.

There are no cost management issues and the contractor has exceeded the remits achieving a costs savings.

There are no delays and the contractor has exceeded the agreed upon time schedule.

Responses to inquires/technical, service, administrative issues is effective and exceeds government expectations.

Outstanding The contractor has demonstrated an outstanding performance level that was significantly in excess of anticipated achievements and is commendable as an example to others.

The contractor has demonstrated an outstanding performance level that justifies adding a point to the score

The contractor has demonstrated an outstanding performance level that justifies adding a point to the score.

The contractor has demonstrated an outstanding performance level that justifies adding a point to the score.