Attachment_5_-_Revised_PP_Questionnaire.doc

Attachment 5

PAST PERFORMANCE QUESTIONNAIRE

Custodial Services McConnell AFB Kansas

FA4621-17-R-0001

PAST PERFORMANCE QUESTIONNAIRE AND COVER LETTER

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: ____________________

You have been identified as a point of contact for a past performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for a Custodial Service contract at McConnell AFB, KS.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, I can be contacted at (316) 759-4516.

KENNETH A. BUTLER

Contracting Officer

1 Atch

Past and Present Performance Questionnaire

A.

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

Contractor’s Name: __________________________________________________________________ Address: ____________________________________________________________________________

Telephone Number: ________________________ Fax Number: _______________________________

Point of Contact:

Project Title or Brief Description of Work:

Contract Number: _________________________ Dollar Amount: ______________per____________ Contract Period or Dates of Performance Provided by Offeror:

*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.

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.

EMAIL COMPLETED SURVEY FORM TO THE GOVERNMENT:

Send copies of completed surveys directly to the Government at the following email addresses:

derek.owen.1@us.af.mil allison.gochenour@us.af.mil If there are any questions or comments, please contact Derek Owen at 316-759-4213 or by email at derek.owen.1@us.af.mil.

D.

PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, G, S, M, U, and N) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

Performance meets/met contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance was not observed or not applicable to the current effort being reported against.

CONTRACTOR’S NAME: ________________________ CONTRACT N0. _____________________

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

YES/NO

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of Reviewer Date