Attachment 6 LSS Past Performance Questionnaire.doc

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 provide information:

Contractor’s Name:

Telephone Number:

Address:

Fax Number:

Point of Contact

CAGE Code

Project Title and Brief Description of Work: ________________________________________________ Contract Number Provided by Offeror

Dollar Amount:

Base Year

Option I

Option II

Option III

Option IV

Total

What was the contract type? (e.g. T&M, FFP, IDIQ, Cost Reimbursement) ______________________ Contract Period or Dates of Performance Provided by Offeror: ________________________________

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

* 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. RESPONDENT INFORMATION:

Name of Respondent:

___________________________ Title: ____________________________

Address: _____________________

Telephone Number: ___________________ _____________________________

Fax Number:

Email Address: _______________________

C. FAX OR E-MAIL COMPLETED SURVEY FORM TO:

88 CONS/PKBB

ATTN: Shelley Deardorff

(REF: FA8601-10-R-0012)

FAX: 937-656-1412

shelley.deardorff@wpafb.af.mil 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 AND FOR QUESTIONS 29 - 33 AS NECESSARY.

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 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 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.

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER: _______________________

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

Remarks:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FA8601-10-R-0012, Attachment 6, 10 May 2010 When Filled In This Document Is Source Selection Sensitive IAW FAR 2.101 and FAR 3.104