Performance_Questionnaire.doc

Contractor’s Name: _____________________________ Contract Number: _____________________________

PAST PERFORMANCE QUESTIONNAIRE

A. General Information:

Contractor’s Name: ________________________________________________________________ Address: ________________________________ Telephone Number: ___________________

Fax Number: _________________________ Point of Contact: _______________________________________

Contract Number: ______________________________________ Contract Period and Dollar Amount (See Notes ):

Period of Performance: _______________________Amount: __$_______________ Project Title: ____________________________________________________________

Description of Work: ______________________________________________________

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 (21 Jun 10). As part of our evaluation, past performance information older than 3 years will not be considered.

(2) If offeror holds or has held other contracts for asbestos abatement 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: ________________________________

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 4:30 pm Central Standard Time (CST) on July 30, 2010:

Address:

82d Contracting Squadron

Attn: David T. Bustamante 136 K Avenue, Suite 1

Sheppard AFB TX 76311-2746

E-Mail:

david.bustamante@sheppard.af.mil Fax: 940-676-3784 D. Performance Information: Choose the appropriate letter on the scale (E, V, 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.

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 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

Comments:

If Yes, please provide comments:

Yes/No

If Yes, please provide comments:

Yes/No

If Yes, please provide comments:

Yes/No

If No, please provide comments:

Yes/No

How would you rate contractor’s overall performance?

Additional Remarks: _______________________________________________________

SOURCE SELECTION INFORMATION IAW FAR 3.104

FOR OFFICIAL USE ONLY

Attachment 6