Past_Performance_Questionnaire.doc

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION:

Offeror’s Name: ______________________________________________________________ Address: ___________________________________________________________________ Point of Contact: _____________________________________________________________ Project Title and Brief Description of Work: _____________________________________*

Contract Number: __________________________________________________________* Dollar Amount: ___________________________________________________________*

Contract Period or Dates of Performance: _______________________________________* Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

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

B. RESPONDENT INFORMATION:

Name of Respondent:

Title: ________________________________________________________________________ Address: _____________________________________________________________________

Email Address: ______________________________________________________________

Telephone Number: ______________________________

Fax Number:

C. E-MAIL COMPLETED SURVEY FORM TO: shakerra.curry@us.af.mil. If e-mail is not a source of delivery, please contact TSgt Shakerra Curry at (618) 256-9251 or Ms. Marcia Wuebbels at (618) 256-9308.

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, V, S, M, U, and N/A) 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 and exceeds many requirements to the Government’s benefit. The contractual performance being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Performance does not meet some contractual requirements. The contractual performance 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 being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

CONTRACTOR’S NAME: ______________________________________________________

CONTRACT NUMBER: ________________________________________________________

Note: Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

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

· ASME A17.1 and A17.3

· UFC 3-600-01

· NFPA and OSHA Standards

CONTRACTOR’S NAME: ____________________________________________________

CONTRACT NUMBER: ______________________________________________________

Remarks: ______________________________________________________________________________