Atth 4- Past and Present Past Performance Questionnaire 10-R-0029.doc

FA4659-10-R-0029

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 and/or present performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for a repair HVAC-Ground Source Heat Pump-Comm. Sq. HQ. Work to be performed includes; replacing an existing building’s HVAC systems with new zone controlled source heat pump systems and install a loop field nearbyat Grand Forks AFB,ND.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, contact Darrell Haas at 701-747-4041, Email Darrell.haas@Grandforks.af.mil or myself at 701-747-5299 or by email: jeremiah.snedker@grandforks.af.mil.

//SIGNED//

JEREMIAH SNEDKER

Contracting Officer

1 Atch

Past and Present Performance Questionnaire

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.

* 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 of Respondent:

_____________________ Title: ____________________________

Address: _____________________

Telephone Number: ___________________ _____________________________

Fax Number:

Email Address: _____________________

C. FAX COMPLETED SURVEY FORM TO:

TSgt Darrelll Haas

Fax: 701-747-4215

Phone: 701-747-5299 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.

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Attachment 4