Past Performance Survey_Atch 6.docx

FA4626-09-R-0021

FOR OFFICIAL USE ONLY

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: ______________________

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 & Title of Evaluator: _____________________ Company Name: ____________________________

C. SEND COMPLETED SURVEY FORM TO:

341 CCS/LGCP

7015 Goddard Drive, Bldg 145 Malmstrom AFB, MT 59402 ATTN: Gail Carroll

FAX: (406) 731-3748

EMAIL: gail.carroll@malmstrom.af.mil

DUTY PHONE: (406) 731-4028

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

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

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor were satisfactory.

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element 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 of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

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

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

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

YES/NO

YES/NO

OVERALL RATING: ___________________________

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE SELECTION SENSITIVE WHEN FILLED IN IAW FAR 3.104

FOR OFFICIAL USE ONLY