Performance Questionnaire.doc

Attachment 4

FA3010-11-R-0005

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: ____________________ Telephone Number: ____________________

Address: __________________________ Fax Number: _________________________

__________________________ Point of Contact: ______________________

Project Title and Brief Description of Work: _____________________________________* Contract Number Provided by Offeror: ___________________ Dollar Amount: ________*

Contract Period or Dates of Performance Provided by Offeror: ______________________* Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

B. RESPONDENT INFORMATION:

Name of Respondent:

_____________________ Title: ____________________________

Address: _____________________

Telephone Number: ___________________ _____________________________

Fax Number:

Email Address: _____________________

C. FAX COMPLETED SURVEY FORM TO: 81st Contracting Squadron, Keesler AFB, MS

Attn: Eric Dismuke Fax # 228-377-3298 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 OF M or U.

Performance meets contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than 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 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 or 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.

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

Place an “X” in the appropriate column using the definitions matrix above.

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________