Atch_4 _PPQ_DRHA_160615.doc

Attachment 5, Past Performance Questionnaire (PPQ)

FA5613-15-R-0016

Past Performance Questionnaire (PPQ) This acquisition is for Deployment Related Health Assessment (DRHA) Program Services of comprehensive health evaluations/assessments conducted pre- and post-deployment for active duty members assigned to Ramstein Air Base and Geographically Separated Units (GSU) 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 7 WORKING DAYS AFTER RECEIPT TO:

Markus Wendel/Contract Specialist Inge Jenkins/Contracting Officer

700 CONS/LGCA

and

700 CONS/LGCA

markus.wendel.1.de@us.af.mil ingeborg.jenkins.1.de@us.af.mil

+49-631-536-6304 or DSN 489-6304 +49-631-536- 6800 or DSN 489-6800

CONTRACTOR’S NAME:

CONTRACT NUMBER:

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.

Performance meets contractual requirements and exceeds many to your organization’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements and exceeds some to your organization’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with 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 being assessed 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.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Performance was not observed or not applicable to the current effort being reported against.

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

REMARKS/COMMENTS: