Past_Performance_Questionaire.pdf

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

FA560619QA025

Patient Liaison and Medical Translation Services Spangdahlem 52MDG

SECTION A: CONTRACTOR INFORMATION:

(TO BE COMPLETED BY THE CONTRACTOR/OFFEROR BEING EVALUATED)

A. Contractor’s Name and Address: _____________________________________________________________

B. Point of Contact: ________________________________________________________

C. Phone Number (with area code): _________________________________________________________________________

D. Contract Number (If Applicable): __________________________________________

E. Brief description of services: ______________________________________________

F. Contract Type (If Applicable): Firm-Fixed-Price Indefinite-Delivery/Indefinite Quantity Task Order

Cost-Reimbursement

G. Award Date: Scheduled Completion Date: ___________________

H. Period Performance: ______________________________ Current/Final Completion Date: ________________

I. Award Amount: Current/Final Project Amount: _________________

J. Contractor being evaluated performed as the Prime Contractor Subcontractor Supplier on this contract/order.

K. Authorization is hereby granted to provide the information requested in SECTION B of this Questionnaire.

(Signature)

(Name and Title of Authorizing Official) (Date)

SECTION B: RESPONDENT INFORMATION

(TO BE COMPLETED BY THE RESPONDENT/SOURCE THAT IS EVALUATING)

EVALUATED BY:

(Signature) (Company/Evaluator)

(Typed or Printed Name) (Address)

(Title) (City/State/ZIP)

(Date) (Phone

SECTION C. PERFORMANCE INFORMATION: Please check the appropriate column.

Contractor’s Name: _________________________ Contract Number: ________________________

Place an “X” in the appropriate column.

The contractor: Yes No

1. Management Effectiveness at identifying and correcting problems.

2. Responsiveness to Customer Requirements

3. Compliance with established contractual and regulatory requirements and quality standards

4. Compliance with accepted workloads and established schedules

5. Experience and training of personnel accomplishing work

6. Were corrective actions taken to avoid repeat problems

7. Condition of equipment and materials

8. Integrity of Management Personnel and personnel accomplishing work

9. Timely response to on-site problems (NOTE: In this case, “timely” is defined as a few hours)

10. Work accomplished without damage to property and structures

11. Overall satisfaction with contractor performance

Remarks:_____________________________________________________________________________