ATTACHMENT 5 PAST AND PRESENT PERFORMANCE QUESTIONNAIRE.doc

ATTACHEMENT # 5

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive IAW FAR 2.101 and FAR 3.104 A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name:

Address: __________________________

Telephone Number:

Fax Number:

Point of Contact:

Project Title or Brief Description of Work:

Contract Number Provided by Offeror:

Dollar Amount:

Contract Period or Dates of Performance Provided by Offeror:

*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.

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

B. RESPONDENT INFORMATION:

Name of Respondent:

_____________________ Title:

Address: _____________________

Telephone Number: ___________________ _____________________________

Fax Number:

Email Address:

C. FAX COMPLETED SURVEY FORM TO:

D. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2.

CONTRACTOR’S NAME: ________________________ CONTRACT NUMBER________________

The contractor:

CONTRACTOR’S NAME: ________________________ CONTRACT NUMBER_______________

Remarks:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

� The government enters the following information based on list of references provided by the offeror. The offeror will enter this information if the solicitation requires him to submit questionnaires to the references.

� If desired, the “Unknown Confidence” rating may be numerically placed in the questionnaire form between “Little Confidence” and “Satisfactory Confidence”.

� Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

� 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.