Attachment 10 Past Performance Survey Distinctive.doc

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FA7000-11-T-0044

Attachment 10

PAST PERFORMANCE SURVEY

This attachment will not be incorporated into the resultant contract.

THIS DOCUMENT, WHEN COMPLETED, IS ONLY FOR VIEW BY THE GOVERNMENT.

This survey is for the United States Air Force Academy Contracting Office.

I. CONTRACT INFORMATION:

Complete the following information on the contractor that provided or is currently providing services for your company.

Contractor’s Name: _____________________________________________________________________ Address: _____________________________________________________________________________

Telephone Number: ____________________________________________________________________

Point of Contact: ______________________________________________________________________

Project Title or Brief Description of Work: __________________________________________________* Contract Number: ___________________________________________________________________* Contract Value Per Year: ________________________________________________________________ Contract Period or Dates of Performance: ___________________________________________________* *Note: If offeror holds or has held more than one contract with your agency/organization in the last three years, please complete separate evaluation forms for those contracts as well.

II. SURVEY RESPONDENT INFORMATION:

Complete the following information on your company. You may be contacted for additional information pertaining to the past or present performance of the contractor identified in the section above. (The following information will assist in the analysis of the data. Information will be kept confidential.)

Name of Respondent: __________________________________________________________________________________

Company/Organization: ________________________________________________________________________________

Title: _______________________________________________________________________________________________

Address: ____________________________________________________________________________________________

Telephone Number: ___________________________________________________ Fax Number: ____________________ Relationship and time involved with Program/Contract:

Date you completed this questionnaire:

FAX or E-MAIL COMPLETED SURVEY FORM TO:

FAX: LGCB ATTN: Brenda Smith, Contract Specialist or Diana Myles-South, Contracting Officer, USAFA CONTRACTING, FAX (719) 333-9075.

EMAIL: brenda.smith@usafa.af.mil or diana.myles-south@usafa.af.mil

III. PERFORMANCE INFORMATION:

Choose the description of the contractor’s work that best reflects their performance using the descriptions provided below. Please provide a narrative explanation for any ratings of unsatisfactory, marginal, very good or exceptional and any other specific problems or annotations that would help us evaluate the contractor.

Performance meets contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than 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 contains some minor problems for which corrective actions taken by the contractor were satisfactory.

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

QUALITY

Comments:_____________________________________________________________________

SCHEDULE

BUSINESS RELATIONS

Comments:

9. FOR LARGE BUSINESSES ONLY: Did the contractor meet disadvantaged small business, women-owned small business, HUBZone small business, veteran-owned small business, service disabled small business, controlled business participation, and subcontracting goals?

( ) Yes

( ) No

Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. QUALITY/SCHEDULE/BUSINESS RELATIONS: Based on your judgment of the contractor’s performance, would you award another contract to this contractor for the same services again? Please explain.

( ) Yes

( ) No

Comments:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. ADDITIONAL COMMENTS:

Thank you for you for completing this questionnaire.

The completed survey will ONLY be viewed by the Government. Do not submit a copy of the completed survey to anyone other than Brenda Smith, Contract Specialist, at brenda.smith@usafa.af.mil or Diana Myles-South, Contracting Officer at diana.myles-south@usafa.af.mil.

****FOR OFFICIAL USE ONLY, ONCE COMPLETED****

PLEASE ANSWER ALL QUESTIONS. PLEASE PROVIDE ADDITIONAL COMMENTS FOR EACH QUESTION.

*** FOR GOVERNMENT USE ONLY ONCE COMPLETED ***

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** FOR GOVERNMENT USE ONLY ONCE COMPLETED **