Atch_5 _PPQ_19May15.doc

Attachment 5, Past Performance Questionnaire (PPQ)

FA5613-15-R-0007

Past Performance Questionnaire (PPQ) This acquisition is for A Occupational Health Care (OHC) and Consultation Service of Local National Civilians at Ramstein, Spangdahlem Air Base and their Geographically Separated Units (GSUs) in Germany A.

GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: ____________________ Address:

Telephone Number: ____________________

Email Address:

Point of Contact:

Project Title or Brief Description of Work*:

Contract Number*:

Contract Amount:

Contract Period or Dates of Performance*:

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

To be completed by the respondent and returned directly to the contracting office.

* 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.

RATER INFORMATION:

Name of Rater:

Title:

Address:

Phone Number:

Email Address:

C. RETURN COMPLETED SURVEY FORM WITHIN 4 WORKING DAYS AFTER RECEIPT TO:

Claudia Ledig/Contract Specialist Inge Jenkins/Contracting Officer

700 CONS/LGCA

and

700 CONS/LGCA

claudia.ledig.de@us.af.mil ingeborg.jenkins.1.de@us.af.mil

+49-631-536-0014 or DSN 489-0014 +49-631-536- 6800 or DSN 489-6800

CONTRACTOR’S NAME:

CONTRACT NUMBER:

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.

REMARKS/COMMENTS: