Attachment_3_OWS_Past_Performance_Questionnaire_R1.doc

Source Selection Sensitive Information (See FAR 2.101 & 3.104)

Attachment 3 – Past and Present Performance Questionnaire

SUBJECT: Request for Past Performance Evaluation

TO:

You have been identified as a point of contact for a past and/or present performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for an Oil Water Separator Maintenance Services contract at Edwards AFB, CA.

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, I can be contacted at ________________________________.

Please submit completed questionnaire to the Government Contract Specialist identified on the attached questionnaire.

Contractor Signature

1 Attachment:

Past and Present Performance Questionnaire

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 and 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:

Email Address:

C. Voluntary Protection Program (VPP)

Pursuant to Voluntary Protection Program (VPP) requirements, include your Total Case Incident Rate (TCIR) and Days Away, Restricted or Transferred (DART) rate for the three most recently reported years of each contract submitted for consideration.

On page 5 in the remarks portion, explain in detail any submitted rates that exceed industry averages as defined by the Bureau of Labor Statistics (http://www.bls.gov/iif/) according to the applicable contract NAICS code (e.g. for contracts with NAICS codes beginning with 811310, rates exceeding 1.1 for TCIR and 0.5 for DART, based on the most recent reported year of data, 2012).

D. SEND COMPLETED SURVEY FORM TO (E-mail is Preferred Method):

Timothy Palen

Richard Barzaghi

AFTC/PZRA

AFTC/PZRA

timothy.palen@edwards.af.mil richard.barzaghi@edwards.af.mil

E. PERFORMANCE INFORMATION:

Choose the appropriate letter on the scale (E, G, S, M, U, N) that most accurately describes the contractor’s performance or situation or N/A if performance in this area is not applicable to the effort addressed.

PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

Performance meets contractual requirements and exceeded many 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 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 #:

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

Remarks:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Attachment 3