Attachment_4_Data_Sheet_for_Performance_Survey.pdf

RFQ # FA4407-13-R-0002

ATTACHMENT 4

DATA SHEET FOR PERFORMANCE SURVEY

PURPOSE: Performance information relevant to RFQ # FA4407-13-R-0002 for the acquisition of ALS Ambulance Services at Scott Air Force Base, IL. Government RFQ Point of Contact (POC): Joe Pasqualucci, Contract Administrator Commercial Phone: 618-256-9288. Government DSN: 576-9288. Fax Number: 618-256-2649

INSTRUCTIONS TO PRIME OFFEROR: Offerors shall complete one of these attachments for yourself and one for each division(s), major subcontractor(s), teaming partner(s), joint venture partner(s), or key person(s) the offeror wants the government to consider in the performance evaluation. YOUR NAME AND ADDRESS, AS THE PRIME OFFEROR, MUST APPEAR IN BLOCK 1 BELOW. Enter the name and address of the firm or individual you want surveyed in Block 2. If no name appears, only the firm or individual in Block 1 will be surveyed.

NOTE 1: Offerors shall complete a separate data sheet for each contract for itself (up to a maximum of 5) and each additional entity the offeror wants the government to consider (up to a maximum of 5 for each entity). *For Key Personnel to be evaluated project information in the same format below shall be provided--resumes will not be evaluated.

NOTE 2: Offerors shall submit this information with Part II of their proposal.

NOTE 3: Subcontractor Consent: Failure to provide written consent may result in information not being evaluated.

1. Name and address of Prime Contractor

REQUIRED

OFFEROR INSERT RESPONSES HERE

2. Name and address of subcontractor, team partner, joint venture or key person to be surveyed. INSERT

“NONE” IF ONLY PRIME CONTRACTOR WILL

BE SURVEYED.

3. Name and address of agency holding the contract

4. Name and title of person to contact at the agency

5. Telephone number of POC in Block 4

6. Fax number of POC in Block 4

7. E-mail address of POC in Block 4, if known

8. Exact Contract/Project Title, Contract Number, and Contract Type (Firm Fixed Price, IDIQ, Cost Type, Cost plus Fixed Fee, MACC, MATOC, etc.)

9. Brief project description including discussion as to its relevancy to this acquisition (may be expressed as a percentage of the work to be performed (i.e. 30% paving, 40% design, etc.)

10. Dollar amount of project in Block 8 (include base price plus all options)

11. Period of performance and final contract completion date of project

OFFEROR INSERT RESPONSES HERE