Attch_4_PPS.doc

Attachment 4 To

Solicitation No. FA5209-13-T-0091

PRESENT/PAST PERFORMANCE SURVEY

履行履歴調査票

Date:

FROM: 374 CONS/LGCB

Unit 5228, Bldg 620 Yokota Air Base

Fussa-shi Tokyo 197-0001

1. INSTRUCTION: The contractor, who sent this survey, has provided the following project as a reference for their present/past performance. Please provide frank, concise comments regarding your assessment of the contractor’s performance regarding this project. When responding to the descriptive statements, choose the rating that most accurately describes the contractor’s performance or situation. The ratings correspond with the following descriptive values. In accordance with FAR 15.306(e)(4), the names of individuals providing reference information about an offeror’s past performance shall not be disclosed. 横田基地契約中隊では在日米軍の業務委託契約において応札業者の受注実績とその履行内容を落札の選定基準に加えております。つきましては貴殿の率直で簡潔なご意見を頂きたく添付の調査票をお送りした次第です。下記の説明に最も近いと思われる評価を項目別にご回答願います。尚、米国連邦調達規則に則り回答者のお名前は公表いたしません。

RATING SCALE 評価の目安

(E)xceptional （超優良）: Performance meets contractual requirements and exceeds many to the customer’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective. 契約内容を満たした上でさらに多くの利益を顧客に与えた。対象の業務は業者の有効な是正措置で問題なく完了した。

(V)ery (G)ood （大変満足）: Performance meets contractual requirements and exceeds some to the customer’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective. 契約内容を満たした上でさらに、高い満足が得られた｡ 対象の業務に軽微な問題が生じても、業者は有効な是正処置を取って完了した。

(S)atisfactory （満足）: Performance meets contractual requirements. The contractual performance of the element or sub-element being assessed contains some minor problems for which corrective actions taken by the contractor were satisfactory. 契約要件は満たしている。履行中に軽微な問題が生じたが、業者の是正処置は満足であった。

(N)eutral （どちらでもない）: Did not observe performance in this area. 履行内容に該当なし。

(M)arginal （不満）： Performance does not meet some contractual requirements. The contractual performance of the element or sub-element reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented. 履行は一部不完全であった。対象の業務に、業者の是正手段の不備による重大な欠陥がある。業者の改善策は有効でないか十分に実行されていないと思われる。

(U)nsatisfactory （大変不満）: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-elements being assessed reflects a serious problem for which corrective actions were not accomplished. The contractor did not take any corrective actions. 契約内容を満たしておらず、期間内に改善の見込みなし。契約した業務は完了せず、業者は是正処置を怠った。

2. CONTRACT INFORMATION (応札する業者が記入): The below listed contractor has identified they provided or are currently providing services for your company/agency.貴殿との委託業務は以下の通りです。

a. Contractor (Company/Agency) 契約者:

b. Contractor Address/Phone契約者の住所・電話番号:

c. Prime contractor or subcontract主契約者 または 再委託契約者 (元請/下請)

d. Title of Program/Contract 契約件名:

1) Contract Number 契約番号:

2) Period of Performance 契約期間:

3) Services Provided (explain in detail the type of services provided by the contractor) 業務の内容:

e. Total Contract Amount 契約金額:

3. RESPONDENT IDENTIFICATION (回答者、評価者が記入): (This information will be kept confidential in accordance with FAR 15.306(e)(4). You may be contacted for additional information pertaining to past or present performance of the contractor identified in section 1 above. ご回答の内容は公表いたしません。審査の手続き上、再度連絡を取らせていただく場合がありますので、ご理解、ご協力お願いします。

a. Company’s Name会社名:

b. Name and Title お名前と役職:

c. Phone Number 電話番号: _______________ FAX ファックス: ______________

E-mail Address 電子メールアドレス： ＿＿＿＿＿＿＿＿＿＿＿

d. Address 住所: _________________________________________

e. Relationship to Project 契約案件における地位： ________________________________________________

f. Length of Involvement in Project 契約案件の担当年数: ______________

g. Date Questionnaire Completed 回答日: ___________

4. QUESTIONNAIRE 調査票 (Circle Oneいずれかに｢(｣を付けてください)

a. (Quality of Work) Were you satisfied with the quality of service performed or items supplied?

E VG S N M U

提供されたサービスや商品の満足度。

b. (Quality of Work) How effective did the contractor’s quality control and/

E VG S N M U

or inspection procedures operate ?

品質管理と作業上の検査手順は妥当か？

契約者の作業は迅速で予定の納期に間に合ったか？

契約者は作業上の懸案、問題解決、苦情処理に長けていたか？

契約者の作業は関連する全ての法規や安全基準を守っているか？

f. Would you hire this contractor again? If no, why?

YES

NO

需要があれば、またこの業者に依頼したいか？

g. Overall Rating 総合評価:

E VG S N M U

h. Additional Comments/Remarks その他:

Please fax or e-mail completed questionnaires to the address shown below:

下記記のファックス番号もしくは、電子メールアドレスにご回答の返送お願いします。

374 CONS/LGCB

Unit 5228, Bldg 620 Yokota Air Base

Fussa-shi Tokyo 197-0001

Attn: Sra Joshua Banks

Fax: 011-8142-530-3319

Tel: 011-8142-552-7102 E-mail: joshua.banks.5@us.af.mil 〒197-0001

東京都 福生市 在日米軍 横田基地内

建物番号620 374契約中隊

SrA Joshua Banks ファックス: 042-530-3319

電話: 042-552-7102

電子メール： joshua.banks.5@us.af.mil

FOR OFFICIAL USE ONLY