FA520525R0001_Atch5_Past Performance Questionnaire_4Mar25.pdf

Controlled Unclassified Information When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Attachment 5 to RFP No. FA520525R0001 Date: 4 Mar 25

Section 1: Contract Identification

A. Contractor (Company/Division):

B. Contractor Cage Code:

C. Contract Number:

D. Contract Type (e.g., Firm-Fixed-Price (FFP), Fixed-Price-Incentive-Fee (FPIF), Cost-Plus-Incentive-Fee (CPIF), Cost-Plus-Fixed-Fee (CPFF), etc.):

E. Contract Title:

F. Period of Performance

1. Original Schedule (assuming all options exercised):

Beginning Date ____________ through ____________

2. Current Schedule (assuming all options exercised):

Beginning Date ____________ through ____________

3. Reason for difference (if applicable):

G. Contract Value

1. Original maximum contract value (assuming all options exercised):

2. Current maximum contract value (assuming all options exercised):

3. Reasons for difference between original and current contract value (if applicable):

H. Description of work performed:

I. Was this a competitively awarded contract? ☐ Yes ☐ No

J. Contractor’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Key Personnel

Attachment 5 to RFP No. FA520525R0001 Date: 4 Mar 25

Section 2: Customer or Agency Identification

A. Customer or agency name:

B. Customer or agency description (if applicable):

C. Geographic description of services under this contract (i.e., local, nationwide, worldwide, other Commands):

Section 3: Respondent Identification

A. Respondent’s name:

B. Respondent’s title:

C. Respondent’s phone number / fax number / e-mail address:

D. Respondent’s position (e.g., Program Manager, Contracting Officer, etc.):

E. Length of time (number of years/months) respondent worked on subject contract and description of responsibility/position/role:

Section 4: Performance Information

In the tables below, indicate your rating for the contractor’s performance by placing an “X” in the appropriate block to the right of each question. Provide supporting information for each response in the space provided.

Attach additional pages if more space is needed. The performance rating scale is defined as follows:

Code Performance Rating

E EXCEPTIONAL – Performance meets contractual requirements and exceeds many requirements to the Government’s benefit. The contractual performance being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

V VERY GOOD – Performance meets contractual requirements and exceeds some requirements to the Government’s benefit. The contractual performance being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

S SATISFACTORY – Performance meets contractual requirements. The contractual performance being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL – Performance does not meet some contractual requirements. The contractual performance 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.

Attachment 5 to RFP No. FA520525R0001 Date: 4 Mar 25

U UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N/A NOT APPLICABLE – Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

Quality E V S M U N/A

Q1. Adherence to required quality of service performance.

Q2. Quality and timeliness of required documentation and reporting.

Q3. Identification and correction of deficient work in a timely manner.

Schedule E V S M U N/A

S1. Completion of required work in a timely manner.

S2. Adherence to approved service schedule.

S3. Resolution of delays.

Management E V S M U N/A

M1. Interaction between the contractor and the customer.

M2. Coordination and control of subcontractors.

M3. Effectiveness of job-site supervision.

Attachment 5 to RFP No. FA520525R0001 Date: 4 Mar 25

Regulatory Compliance E V S M U N/A

R1. Compliance with safety and environmental regulations.

R2. Compliance with environmental reporting requirements.

Overall Rating E V S M U N/A

O1. Based on the above, what is your overall assessment of the present/past performance for this contractor?

Government Contracts Only: Was this contract partially or completely terminated for default or convenience, or are there any pending terminations?

☐ Yes ☐ Default ☐ Convenience ☐ Pending Terminations ☐ No

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules).

SECTION 5: GENERAL COMMENT

Given what I know today about the contractor’s ability to execute what he promised in his proposal, I

[☐ definitely would, ☐ probably would, ☐ might or might not, ☐ probably would not, ☐ definitely would not] award to him today given that I had a choice.

Please provide any additional comments concerning this contractor’s performance, as desired.

Respondent’s Signature Date

Attachment 5 to RFP No. FA520525R0001 Date: 4 Mar 25

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

E-Mail: Ms. Miyako Fujimoto (miyako.fujimoto.jp@us.af.mil) Mr. Kazuo Miura (kazuo.miura.jp@us.af.mil)

Mailing Address: 35th Contracting Squadron Attn: Ms. Miyako Fujimoto Bldg. 656, Misawa Air Base, Hirahata, Misawa-shi, Aomori-ken, Japan 033-0012

FAX: 011-81-176-52-4793 (Attn: Ms. Miyako Fujimoto and Mr. Kazuo Miura)