Attachment_5_Past_Performance_Questionnaire.pdf

RFQ # FA4407-13-R-0002

Attachment 5

PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive Information IAW FAR 3.104

A. GENERAL INFORMATION: Offerors shall forward this Attachment for completion to each contract/reference the offeror wants the government to consider. Offerors shall ensure each respondent submits a completed survey directly to the Contracting Officer by the closing date of the RFQ. Offerors are encouraged to have respondents submit the information from Attachment 3 prior to the closing date of the RFQ.

Contractor’s Name:

Project Title or Brief Description of Work:___________________________________________________________

Contract Number Provided by Offeror: Dollar Amount:_______________________

*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. AGENCY INFORMATION: Work to be performed: ALS Ambulance Services

Offeror submitted as:

Prime Contractor Sub-Contractor Key Personnel Teaming/Joint Venture Architect/Engineer

C. RESPONDENT INFORMATION (Person who is completing information):

Name of Respondent: _____________________ Title: _______________________________

Address: ______________________________ Telephone Number: ____________________ ______________________________ Fax Number: _________________________ ______________________________ Email Address: _______________________

Contractor performed as:

Prime Contractor Sub-Contractor Key Personnel Teaming/Joint Venture Architect/Engineer

D. FAX COMPLETED SURVEY FORM TO: 618-256-2649

E. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance or situation. If there was no performance in this project that can be rated use “Not Applicable (N/A)”. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2.

1 2 N 3 4 5

No Confidence Little Confidence Unknown Confidence

Satisfactory Confidence

Significant Confidence High Confidence

Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.

Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective.

The record is inconclusive or without comment or the contractor did not perform this effort.

Performance met contract requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory.

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

Performance met all contract requirements and exceeded many requirements.

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

Technical Expertise and Project Supervision 1 Contractor provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

1 2 N 3 4 5

2 Contractor hired and retained field workers with appropriate technical skills and training commensurate with those required for successful project completion.

1 2 N 3 4 5

3 Contractor delegated authority to project managers and supervisors commensurate with contract requirements.

Project manager’s role was clear.

1 2 N 3 4 5

4 Provided on-site superintendent at all times, or as otherwise required by the specific contract.

1 2 N 3 4 5

Home Office/On-Site/Government Interaction 5 Identified risks/problems as they occurred and offered constructive and/or viable solution/alternatives.

1 2 N 3 4 5

6 Contractor was responsive and reasonable to contract changes from the standpoint of timeliness, suggested solutions, and price.

1 2 N 3 4 5

7 Contractor displayed a cooperative attitude with company/government personnel before and after award.

1 2 N 3 4 5

8 Contractor’s on-site supervisor displayed initiative to resolve problems on-site.

1 2 N 3 4 5

9 Were there any claims by subcontractors/suppliers for non-payment. If yes, please explain outcome in “Remarks”.

YES NO

Project Specific Questions 10 N/A

Service Quality 11 Contractor provided and followed effective quality control plan and/or inspection procedures to meet contract requirements.

1 2 N 3 4 5

12 Contractor’s emphasis on delivering a quality service was apparent in day-to-day operations.

1 2 N 3 4 5

13 Contractor corrected deficiencies in a timely manner and pursuant to their quality control procedures.

1 2 N 3 4 5

14 Contractor maintained a quality workforce and subcontractors through project completion.

Schedule

15 Developed realistic progress schedules and met established project milestones.

16 Contractor provided the required Reports/Documentation as required in the contract.

1 2 N 3 4 5

Other

17 Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in "Remarks."

YES NO

18 Would you award another contract to this contractor? If not, explain in "Remarks."

YES NO

OVERALL ASSESSMENT

19 Overall, on the scale of 1 – 5, how would you rate the contractor being surveyed

Remarks: