Attachment_3_-_Past_Performance_Questionnaire.docx

For Official Use Only When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

FA557018R0005 Attachment 3 - Past Performance Questionnaire Section A: Contract Identification

Contractor Company Name:

Contractor Company Cage Code:

Past Performance Contract Title (Include Contract Number if US Government-Issued Contract):

Past Performance Contract Period of Performance

1. Original Schedule:

Beginning Date _________ through ____________

2. Current Schedule:

Beginning Date _________ through ____________

3. Reason for difference (if applicable):

Past Performance Contract Price

1. Original contract price:

2. Current contract price:

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

Description of past work performed (Please be specific to include quantities, distances, operating locations, etc.):

Offeror’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Key Personnel

Section B: Respondent/Customer Identification

Respondent’s name:

Respondent’s title:

Respondent’s company or organization:

Respondent’s phone number / e-mail address:

Respondent’s title (e.g., Program Manager, PCO/ACO, Director, etc.):

Dates (start and end) respondent worked on subject contract and description of responsibility/position/role:

Other suggested points of contact (if any):

Are there any discrepancies between the work as described in Section A and the work actually performed:

Section C: Performance Information

In the tables below, indicate your rating for the contractor listed in Section A’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:

SUPPORTING INFORMATION:

US 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).

Given what I know today about the contractor’s ability to execute work in accordance with his proposal and the terms of the contract, I [ click and select an item ] hire or award a contract to the contractor again.

REMARKS:

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

[click and pick the date]

Respondent’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing Address:

501 CSW/RCO, Bldg 516, RAF Alconbury, Huntingdon, Cambridgeshire PE28 4DA, UK or 501 CSW/RCO, Unit 5720, APO, AE 09470-5720 USA

E-Mail to:

mason.harney@us.af.mil and 501csw.rco@us.af.mil

For Official Use Only Page 1 of 4