Attachment 4 Past Performance Questionnaire.pdf

ATTACHMENT 4 Contractor’s Name: _______________

Contract Number: _______________

SOURCE SELECTION INFORMATION IAW FAR 3.104

FOR OFFICIAL USE ONLY

PAST PERFORMANCE QUESTIONNAIRE

A. General Information: Please correct any information below known to be inaccurate:

Contractor’s Name: ________________________________________________________________

Address: ________________________________ Telephone Number: ___________________

________________________________ Fax Number: _________________________

Point of Contact: _______________________________________

Contract Number: ______________________________________

Contract Period or Dates of Performance and Dollar Amount (See Notes):

Basic Period of Performance: _______________________Amount: __$_______________

Option Period One of Performance: __________________Amount: __$_______________

Option Period Two of Performance: __________________Amount: __$_______________

Option Period Three of Performance: _________________Amount: __$_______________

Option Period Four of Performance: __________________Amount: __$_______________

Total Contract Amount: _$__________________________

Project Title: ____________________________________________________________

Description of Work (include approximate number of machines):

Contractor performed as the Prime Contractor Sub-Contractor Key Personnel

Notes

(1) When assessing past performance, only performance that occurred within the last three (3) years prior to the issuance date of this solicitation (F3V3E12121A001 ) will be considered. As part of our evaluation, past performance information older than 3 years will not be considered. Most recent contracts must have been performed for at least 6 months prior to the issuance date of this solicitation to be considered.

(2) If offeror holds or has held other contracts for Washers and Dryers Maintenance, Repair and Lease services with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

(3) If the total dollar amount of the contract was/is for more than one year, indicate the dollar value for each year/option period and then give the total value of the contract.

B. Respondent Information:

Name of Respondent: _____________________________Title: __________________________________

Address: ______________________________________________________________________________

Telephone Number: ___________________________Fax Number: ________________________________

E-mail Address: ________________________________________

C. Mail, Electronically Mail, or Fax Completed Survey Form to the address below. The survey needs to be received no later than 4:00 pm Central Standard Time (CST) on Friday, August 17, 2012:

Address: 82d Contracting Squadron

Attn: Sharon T. McCreary

206 J Avenue, Bldg 1662

Sheppard AFB TX 76311-2743

E-Mail: sharon.mccreary@sheppard.af.mil or brenda.alvarado@sheppard.af.mil

Fax: 940-676-3784 mailto:sharon.mccreary@sheppard.af.mil mailto:brenda.alvarado@sheppard.af.mil

D. Performance Information: Choose the appropriate letter on the scale (E, G, S, M, U, and N) that most accurately describes the contractor’s performance or situation. Please provide a narrative explanation for any ratings that are Exceptional, Marginal or Unsatisfactory.

E G S M U N

Exceptional Good Satisfactory Marginal Unsatisfactory Neutral

Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Performance does not meet some contractual requirements.

The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner.

The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Performance was not observed or not applicable to the current effort being reported against.

Assign a Performance Rating by placing an “X” in the appropriate column

1 Contractor provided experienced key personnel that met or exceeded the qualifications of the position as described in the contract.

Comments:

2 Contractor delegated authority to project managers and supervisors.

3 Contractor supported actions taken by key personnel.

4 Contractor participated in solving significant local problems.

5 Contractor provided replacement of key personnel, when necessary, with personnel that met or exceeded the qualifications of the position as described in the contract.

6 Accuracy and timeliness of schedules, milestones and administrative requirements.

7 Met established schedules.

8 Accuracy and timeliness of invoices.

9 Contractor interaction with the Government.

10 Contractor’s behavior is reasonable and cooperative.

11 Contractor is customer oriented.

12 Contractor followed accepted Quality Control Plan to meet contract requirements.

13 Contractor corrected deficiencies in a timely manner and in accordance with Quality Control Plan.

14 Contractor identified and displayed initiative to resolve issues/problems in a timely manner.

15 Contractor suggested alternative approaches to issues/problems.

16 Contractor was responsive to contract changes.

17 Contractor cooperated with Government after contract award.

18 Has the contractor ever had financial difficulties (making payroll, payments to sub-contractors, employees, etc.)?

If Yes, please provide comments:

Yes/No

19 Has the contractor ever received a notice of noncompliance? (Law, Regulations, Environment, Safety, etc.)?

20 Was the contractor ever issued a cure show notice?

21 Was the contractor ever issued a show cause notice?

22 Would you award another contract to this contractor?

If No, please provide comments:

23 Is the contractor rated in CPARS?

Comments:

Yes/No

E G S M U N

How would you rate contractor’s overall performance?

Additional Remarks: _______________________________________________________