Attach 6 Past Performance Questionnaire.docx

"SOURCE SELECTION SENSITIVE IAW FAR 3.104 WHEN FILLED IN"

Attachment 006 FA4626-12-R-0007

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION:

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

Submitting Survey as Prime or Sub-Contractor (please circle one) If submitting as Sub-Contractor, Prime Contractors Name:___________________________ Address: __________________________ Fax Number: _________________________ __________________________ Point of Contact: ______________________

Project Title and Detailed 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 3 years, please complete separate evaluation forms for those contracts as well.

B. RESPONDENT INFORMATION:

Name and Title of Evaluator: ____________________________

Company Name: ______________________________________

C. SEND COMPLETED SURVEY FORM TO:

341 CONS/LGCA, 7015 Goddard Drive, Bldg 145, Malmstrom AFB, MT 59402 ATTN; Deric Blum FAX: (406) 731-1113 EMAIL: deric.blum@malmstrom.af.mil

DUTY PHONE: (406) 731-4031

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: _______________

Note: Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

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

YES/NO

YES/NO

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________