Atch_4_-_Past_Performance_Questionnaire.pdf

PRESENT/PAST PERFORMANCE QUESTIONNAIRE

TO:

RETURN TO: 92 CONS/LGCA

Contracting Officer 110 W. Ent St Fairchild AFB WA 99011

SUBJECT: Present/Past Performance: Contract # , Contractor:

1. Your assistance is respectfully requested in providing information on the attached performance questionnaire. The importance of your opinion cannot be overstated. This survey measures the present/past performance of , a prospective offeror for medical office administration services at Fairchild AFB.

2. INSTRUCTIONS FOR COMPLETION: Fill it in by hand or type and please email the results to the

Contracting Officer, Shane Galles at shane.galles@us.af.mil and to the Contract Administrator, SSgt Charles McAvoy at charles.mcavoy@us.af.mil. Email submissions are preferred. You can also send by mail to the address listed above. Please direct questions to Shane Galles at (509) 247-2163 or SSgt Charles McAvoy at (509) 247-2236.

Your participation is greatly appreciated.

Explanation of codes:

Code PERFORMANCE LEVEL

RATING DEFINITION

E Exceptional Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort.

G Good Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort.

S Satisfactory Based on the offeror’s performance record, some doubt exists that the offeror will successfully perform the required effort.

N Neutral No performance record identifiable.

M Marginal Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Changes to the offeror’s existing processes may be necessary in order to achieve contract requirements.

Circle the appropriate letter for each item on the questionnaire and provide narrative justification.

Attachment 4 - Past Performance Questionnaire

PRESENT / PAST PERFORMANCE

EVALUATION QUESTIONNAIRE

SOLICITATION NO: FA4620-16-R-A012 Med Admin 5

Section A: Contractor Information.

Contractor’s name and address:

a. Point of Contact:

b. Phone #:

c. Contract Number:

d. Project Title:

e. Period of Performance:

SECTION B: RESPONDENT INFORMATION

a. Respondent’s name and address: Organization:

Address:

City: State: Zip: _

b. Respondent’s Name and Title:

Signature:

c. Commercial Phone #: _ DSN Phone #:

Fax #: E-Mail:

d. Contract Type:

e. Award Amount: $ Final Amount: $

f. What was the job title for this position?:

g. Was the position full time on site?:

h. Did the position require clearance to work on classified networks?

i. What duties/responsibilities did this job entail?:

Please email or FAX the completed questionnaire by 5 Aug 2016 to:

92 CONS/LGCA

ATTN: SSgt Charles McAvoy and Shane Galles EMAIL:

charles.mcavoy@us.af.mil/shane.galles@us.af.mil

FAX: (509) 247-8685

DSN FAX: 657-8685

If you have questions regarding this questionnaire, please call SSgt McAvoy at (509) 247-2236.

Performance Evaluation Instructions: When responding to the descriptive statements, select the number which most accurately describes the contractor’s performance or situation. If the contractor has no record of past performance relevant to a particular question, select “N/A” for “Neutral”.

Evaluation of the Contractor’s Performance: For any ratings less than satisfactory, please provide explanation in Remarks section below.

PERFORMANCE:

1. How effective was the contractor’s recruitment plan for filling the required

N/A positions and providing replacements for personnel that discontinued employment under this contract?

2. How effective was the contractor in maintaining professional business relationships with government personnel and in resolving contract issues?

1 2 3 4 5 N/A

3. How well did the contractor personnel perform assigned office administration duties?

1 2 3 4 5 N/A

4. How was the overall appearance and professionalism of contractor

N/A personnel?

5. How well did personnel perform records management and documentation?

1 2 3 4 5 N/A

6. Was the contractor personnel knowledgeable and experienced in their position?

1 2 3 4 5 N/A

PAST PERFORMANCE ASSESSMENT

Rating Description

Exceptional (5) Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort.

Good (4) Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort.

Satisfactory (2-3) Based on the offeror’s performance record, some doubt exists that the offeror will successfully perform the required effort.

Marginal (1) Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Changes to the offeror’s existing processes may be necessary in order to achieve contract requirements.

Neutral (N/A) No performance record identifiable.

CORRECTIVE ACTION HISTORY:

1. Have there been any show cause or cure notices issued or legal actions taken? (circle one) YES

NO

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules).

2. If Contract Discrepancy Reports (CDR) were issued, were they addressed appropriately? If so, how? (circle one) YES

NO N/A

If yes, explain and indicate the status.

EVALUATION SUMMARY:

1. Overall evaluation of the contractor. (Circle one and explain.) 1 2 3 4 5

2. Would you enter into another contract with this contractor? (circle one) YES

NO N/A

If no, please explain.

Additional Remarks: