HAMS Attachment F Past Performance Questionnaire.doc

Attachment F

Past and Present Performance Questionnaire Solicitation FA5587-12-R-0006, Hospital Aseptic Management System (HAMS) Services

A. GENERAL INFORMATION:

Vendor’s Name: ____________________ Telephone Number: ____________________

Address: __________________________ Fax Number: _________________________

__________________________ Point of Contact: ______________________

(The government enters the following information based on list of references provided by the vendor.)

Project Title and Brief Description of Work: ___________________________________

Contract Name/Number: ___________________ $/£ Amount: ________________

Contract Period or Project Period of Performance: __________________________

Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

B. RESPONDENT INFORMATION:

Name of Respondent: _____________________ Title: ___________________________

Company/Organization:____________________________________________________

Address: ________________________ Telephone Number: _______________________ _______________________________ Fax Number:____________________________

Email Address: __________________________

C. EMAIL COMPLETED SURVEY FORM TO: claire.switzer@lakenheath.af.mil and darian.vomund@lakenheath.af.mil D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (A or U) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF Unacceptable (U).

Place an “X” in the appropriate column using the definitions matrix above.

Note: While these questions are generic and will work as written in many acquisitions, consider them as they relate to each individual acquisition and tailor them as needed and appropriate. Also, when tailoring the form, consider leaving space between questions for comments.

REMARKS/COMMENTS:

Attachment F Once completed this is Source Selection Information – See FAR 2.101 and 3.104