PP Questionare FY 12.doc

FA5000-11-R-0028

ATTACHMENT 4

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive in accordance with Federal Acquisition Regulation parts 2.101 and 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 Privately Owned Vehicle (POV) storage contract at Joint Base Elmendorf-Richardson (JBER), Alaska.

Please complete the attached questionnaire and send to:

673d Contracting Squadron/LGCB 10480 22nd Street, Suite 368

JBER, AK 99506-2501

lucian.reaves@elmendorf.af.mil Facsimile: (907) 552-7497

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, I can be contacted at

1 Atch

Past and Present Performance Questionnaire

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

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: (907) 552-7497

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

D. PERFORMANCE INFORMATION: Please read the statements below, indicating your relative level of agreement in the box provided: (E, G, S, M, U, and N) PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

Performance meets contractual requirements with many exceeded to the Customer’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 Customer’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 was 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.

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________