A2_-_Past_Performance_Questionnaire_11_Mar_14.pdf

PAST PERFORMANCE QUESTIONNAIRE

23 Apr 2015

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

Contractor’s Name: __________________ Telephone Number: ____________________

Address: __________________________ Fax Number: _________________________

__________________________ Point of Contact: ______________________

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.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 5 years, please complete separate evaluation forms for those contracts as well.

B. RESPONDENT INFORMATION:

Name of Respondent: _____________________ Title: ____________________________

Address: _____________________ Telephone Number: ___________________

_____________________________ Fax Number: _____________________

_____________________________ Email Address: _____________________

C. FAX/EMAILCOMPLETED SURVEY FORM TO: 609-754-4948 karin.bogner@us.af.mil and jeremy.botkin@us.af.mil.

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (EX, VG, S, M, UNS and NA) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE

EXPLANATION FOR ANY RATINGS OF UNS or NA.

PAST PERFORMANCE ASSESSMENT

RATING DESCRIPTION

Execeptional (EX) The contractor’s performance meets contractual requirements and exceeds many

(requirements) to Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good (VG) The contractor’s performance meets contractual requirements and exceeds some

(requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory (S) The contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal (M) Performance does not meet some contractual requirements. The contractual mailto:karin.bogner@us.af.mil mailto:jeremy.botkin@us.af.mil performance 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.

Unsatisfactory (UNS) Performance was not observed or not applicable to the current effort being reported against. Performance does not meet most contractual requirements and recovery is not like in a timely manner. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Not Applicable (NA) Not applicable.

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

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

The contractor: EX VG S M U

N

N

A

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. Followed approved quality control plan.

4. Provided effective quality control and/or inspection procedures to meet contract requirements.

5. Identified and corrected deficiencies in timely manner and pursuant to their quality control procedures.

6. Provided timely resolution of contract discrepancies.

7. Suggested alternative approaches to problems.

8. Provided service in a timely manner.

9. Was responsive to contract changes.

10. Provided adequate contract supervision.

11. Paid subcontractors/suppliers in a timely manner.

12. Cooperated with Government personnel after award.

13. How has the contractor operated, maintained and/or repaired the wastewater treatment plant? Please state the million gallon per day in

“remarks.”

14. Has the contractor successfully monitored and/or reported Lab

Analysis Plans?

15. Has the contractor abided by Federal and State statutes and

Occupational Safety and Health Administration Regulations in regards to safety, security and environmental regulations especially with obtaining and operating plant with appropriate permits, mark outs and sewer line cleaning and stoppages?

16. Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain the outcome in “remarks.”

Yes / No

17. Would you award another contract to this contractor? If not, explain in

“remarks.”

Yes / No

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:_____________________________________________________________________________________

Evaluator’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire No Later Than 6 May 2015 to: FAX 609-754-4948 ATTN: Karin

Bogner and Jeremy Botkin via e-mail to karin.bogner@us.af.mil and jeremy.botkin@us.af.mil .

mailto:karin.bogner@us.af.mil mailto:jeremy.botkin@us.af.mil