Attachment_4_-_Past_and_Present_Performance_Questionnaire.pdf

ATTACHMENT 4 - Past and Present Performance Questionnaire RFP No.: FA5270-17-T-0004

Date

Attachment 4

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

RFP No. FA5270-17-T-0004/ DEPLOYMENT HEALTH REASSESSMENT (DHRA) for

18th Medical Treatment Facilities, Okinawa, Japan contract at Kadena AB, Okinawa, Japan.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, please contact SrA James Molden at DSN-634-

2127(james.molden@us.af.mil/ Comm Tel. 098-961-2127).

1 Atch

Past and Present Performance Questionnaire http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/af_afmc/far/Far02.doc#T2101 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/af_afmc/far/FAR03.DOC#b3104 mailto:james.molden@us.af.mil/

ATTACHMENT 4 - Past and Present Performance Questionnaire RFP No.: FA5270-17-T-0004

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: ______________________

(The government enters the following information based on list of references provided by the offeror. The offeror will enter this information if the solicitation requires him to submit questionnaires to the references.)

Project Title and Brief Description of Work: _____________________________________*

Contract No. 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: _______________________

Signiture Date

C. COMPLETED SURVEY FORM TO:

Attn: SrA James Molden

Tel No.: DSN 634-2127 (Comm. 098-961-2127)

Email: james.molden@us.af.mil

Fax No.: DSN 634-4795 (Comm. 098-961-4795)

**Return completed survey no later than: 22 Feb 2017, 12:00 PM JST mailto:james.molden@us.af.mil

ATTACHMENT 4 - Past and Present Performance Questionnaire RFP No.: FA5270-17-T-0004

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.

E G S M U N

Exceptional Good Satisfactory Marginal Unsatisfactory Neutral

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.

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.

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.

The contractor: E G S M U N

1. Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

2. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

ATTACHMENT 4 - Past and Present Performance Questionnaire RFP No.: FA5270-17-T-0004

The contractor: E G S M U N

3. Delegated authority to project managers and supervisors commensurate with contract requirements.

4. Home office participated in solving significant local problems.

5. Followed approved quality control plan.

6. Provided effective quality control and/or inspection procedures to meet contract requirements.

7. Corrected deficiencies in timely manner and pursuant to their quality control procedures.

8. Provided timely resolution of contract discrepancies.

9. Identified problems as they occurred.

10. Suggested alternative approaches to problems.

11. Displayed initiative to solve problems.

12. Developed realistic progress schedules.

13. Met established project schedules.

14. Was responsive to contract changes.

15. Provided adequate project supervision.

16. Paid subcontractors/suppliers in a timely manner.

17. Provided accurate and complete line item cost proposals including all aspects of work required for each task.

18. Cooperated with Government personnel after award.

19. How would you rate the contractor's overall performance?

20. Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

YE

S/

N

O

21. Would you award another contract to this contractor? If not, explain in “remarks.”

YES/NO

22. Is the contractor rated in CPARS? YES/NO

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks:______________________________________________________________________