PAST PERFORMANCE REQUEST.pdf

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive IAW FAR 2.101 and FAR 3.104

SUBJECT: Request for Past Performance Evaluation

TO: Whom it May Concern

You have been identified as a point of contact for a past and/or present performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for a Inpatient Medicaly Transcription Services contract at Travis AFB, CA.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, contact the Contract Specialist, Jessica Pritchett, at (707) 424- 7723 or jessica.pritchett@travis.af.mil.

CORA L. ARMSTRONG

Contracting Officer

Atch Past Performance Questionnaire

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: ____________________ Telephone Number: ____________________ Address: __________________________ Fax Number: _________________________ __________________________ Point of Contact: ______________________

(The government enters the following information based on list of references provided by the offeror.

The offeror will enter this information if the solicitation requires him to submit questionnaires to the references.)

Project Title and Brief Description of Work: ____________________________________*

Contract Number Provided by Offeror: ___________________ Dollar Amount: ________*

Contract Period or Dates of Performance Provided by Offeror: ______________________* Contractor performed as the Prime Contractor Sub-Contractor Key Personnel.

B. RESPONDENT INFORMATION:

Name of Respondent: _____________________ Title: ____________________________

Address: _____________________ Telephone Number: ___________________ _____________________________ Fax Number: ______________________ _____________________________ Email Address: ______________________

C. FAX COMPLETED SURVEY FORM TO: Jessica Pritchett at (707) 424-0288

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (1, 2, 3, 4, and 5) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 4 or 5.

1 2 3 4 5

Substantial Confidence

Satisfactory Confidence

Limited Confidence

No Confidence Unknown Confidence

Based on the offeror’s performance record, the government has a high expectation that the offeror will successfully perform the required effort.

Based on the offeror’s performance record, the government has an expectation that the offeror will successfully perform the required effort.

Based on the offeror’s performance record, the government has a low expectation that the offeror will successfully perform the required effort

Based on the offeror’s performance record, the government has no expectation that the offeror will successfully perform the required effort

No performance record is identifiable or the offeror’s performance record is so sparse that no confidence assessment rating can be reasonably assigned.

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

The contractor: 1 2 3 4 5

1. Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

2. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

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

4. Home office participated in solving significant local problems.

5. Followed approved quality control plan.

6. Corrected deficiencies in timely manner and pursuant to their quality control procedures.

6. Identified problems as they occurred.

8. Displayed initiative to solve problems.

9. How would you rate the contractor's overall performance?

10 Would you award another contract to this contractor? If not, explain in “remarks

YES/NO

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:_____________________________________________________________________________