Attachment 3 Past Performance Questionaire.docx

ATTACHMENT 3

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: ____________________________________*

Did this project include extracting of Solid Waste, Hazardous Waste, and Storm

Did this project include reporting of finalized analytical reports? YES / NO Did this project include record keeping of work completed /remaining to include but not limited to: Dates of Finalized Sample Reports, Shop Type, Bldg. No., Waste/Test Description, Attempted Pick Up Sample Dates, Proposed Schedule Dates of Remaining Sample Tests to be Completed? YES /NO Did this project include Laboratory Quality Control Requirements being met in accordance with EPA protocols? YES/NO Did this project include Special Qualifications and Certifications being met in accordance with AIBA, PAT, FDEQ, NELAP, EPA’s ( PAP) , and NIOSH? YES / NO

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: ____________________________

C. EMAIL COMPLETED SURVEY FORM TO: michael.winstead@us.af.mil

CONTRACTOR’S NAME: __________________ CONTRACT #___________________

D. PERFORMANCE INFORMATION: Choose the appropriate rating on the scale (SUBCON, SATCON, LIMCON, NOCON, and UNCON) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF NOCON or UNCON.

CONFIDENCE

UNKNOWN CONFIDENCE

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

The contractor:

6.

Home office participated in solving significant local problems.

22.

Was the contractor ever issued a warning of termination or penalty under the referenced contract? YES/NO If yes, explain outcome in “remarks”.

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________

CONTRACTOR’S NAME: __________________ CONTRACT #___________________