RFP FA440709R0002 Past Perf. Questionnare SAFB Attch 3.pdf

Attachment 3

PAST PERFORMANCE QUESTIONNAIRE

SOLICITATION NUMBER FA4407-09-R-0002

1. Please complete the questionnaire based on this guidance:

a. Handwritten responses are sufficient. If you need more space, please attach a separate sheet to the end of this questionnaire.

b. You are urged to supplement your own knowledge of the offeror’s performance with the judgment of others in your activity.

c. Check Yes or No where applicable.

d. Using the rating codes below, check the rating that best describes the contractor’s work on the project and provide a brief explanation of your ratings. If performance was Exceptional or Very Good give examples, likewise for ratings of Marginal or Unsatisfactory.

e. Responses will be treated as source selection sensitive information.

f. Do not provide a copy to the contractor. This is for government use only.

g. Fax, email or mail the completed questionnaire to:

375th CONS/LGCM ATTN: Mr. Darryl E. D. Weaver (Contracting Officer) darryl.weaver@scott.af.mil 201 E. Winters Street, Bldg 50 Scott AFB IL 62225-5015

DSN PH: 576-9286 COMM PH: 618-256-9286

DSN FAX: 576-6012 COMM FAX: 618-256-6012

2. Explanation of codes: Choose the letter that most accurately describes the contractor’s performance or situation.

E VG S NA M U

Exceptional Very Good Satisfactory Not Applicable Marginal Unsatisfactory

Performance met all contract requirements and exceeded many to the government’s benefit.

Problems, if any, were negligible and were resolved in a timely, highly effective manner.

Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems which the contractor resolved in a timely, effective manner.

Performance met contract requirements.

There were problems, some of a serious nature, for which corrective action was satisfactorily effective.

Task was not performed under this specific contract.

Performance did not meet some contractual requirements.

There were problems, some of a serious nature, for which corrective action was only marginally effective.

Performance did not meet most contractual requirements.

There were serious problems and the contractor’s corrective actions were ineffective.

A. Contractor/Contract Information: Please correct any information below known to be inaccurate.

Contractor name:____________________________________ Contractor performed as: ( ) Prime ( ) Sub

Contract Number: * Program name/title/designation:______________________*

Period of Performance: * Contract dollar value: *

Contract type: ( ) Fixed-Price ( ) Cost-Reimbursable ( ) Task Order

*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

1. Name ___________________________________________

2. Mailing Address _________________________________________ Phone: ___________________

E-mail address __________________________________________ Fax: _______________________

3. With respect to the contract identified above, were you (check one):

( ) Program/project manager ( ) Contracting Officer ( ) Other, explain: ________________________

4. How long did you hold the position in Question 3 for this contract? __________

C. General

1. Please provide a short description of the work accomplished under this contract.

2. Was subcontracting used (excluding vendors/suppliers)? ( ) Yes ( ) No ( ) Don't know

If yes, provide us with the name and POC of the subcontractor:_________________________________________

3. Did any of the following actions occur on this contract? If yes, please explain below.

a. Major contract requirements terminated or rescheduled as a result of the contractor's inability to perform.

( ) Yes ( ) No

b. Cure notices or show cause notices issued. ( ) Yes ( ) No

c. Options not exercised due to contractor performance. ( ) Yes ( ) No

Remarks:_____________________________________________________________________________________________

D. Technical Capability

Please rate the contractor on: E VG S M U N/A

Contractor provides employees with appropriate skills, expertise, training, and certifications.

Contractor meets or exceeds customers' requirements on time .

Contractor meets or exceeds required response time in answer to an emergency call.

Contractor provides appropriate treatment and medical care in response to a patient’s condition.

Contractor adapts to schedule changes based on customer’s requirements.

Contractor provides acceptable equipment to perform services.

Contractor has appropriate licensing to perform ambulance services.

GENERAL:

Contractor is efficient in re-performance of incompleted or omitted paperwork.

Contractor provides effective quality control and follows approved quality control plan.

Contractor is cooperative and maintains professional business relationships.

How would you rate this contractor's management of its subcontractors, if any?

How would rate the contractor’s overall performance in providing full emergency patient transport services.

Summary

4. In a competitive situation, all other factors being equal, would you award this contractor another contract based on their past performance? ( ) I definitely would ( ) I probably would

( ) I probably would not ( ) I definitely would not

Please feel free to provide any other information that you believe would help us in assessing the past performance of this contractor.

Please accept our sincere thanks for taking the time to complete this questionnaire.

PAST PERFORMANCE QUESTIONNAIRE