Past_Performance_Questionnaire.pdf

ATTACHMENT 3: Past_Performance_Questionnaire

PAST PERFORMANCE QUESTIONNAIRE AND COVER LETTER

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive IAW FAR 2.101 and FAR 3.104

SUBJECT: Request for Past Performance Evaluation

TO:

You have been identified as a point of contact for a past performance evaluation of the firm listed on the attached questionnaire. This firm is currently being considered for a Chemical Toilet/Hand Wash Station/Septic Tank contract at Edwards AFB, CA.

This form shall not be altered in any way with the exception of entering responses in the provided space(s).

Your prompt attention to this questionnaire will be greatly appreciated. If you have any questions concerning this request, I can be contacted at ___________________ (Contractor contact information).

All responses are to be provided directly to the Government Contract Specialist and Contracting Officer identified in Section C, NOT THE FIRM BEING EVALUATED.

All responses are due NO LATER than 10:00 A.M. PST on 12 March 2015.

Contractor Signature

1 Attachment

Past and Present Performance Questionnaire

FA9301-15-R-0009

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: __________________ Telephone Number: ____________________

Address: __________________________ 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: ______________________* 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 5 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. EMAIL COMPLETED SURVEY FORM TO:

Contract Specialist: Anthony.Trevino.2@us.af.mil

Contracting Officer: Roberta.Ross@us.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

E G S M U N

Exceptional Good Satisfactory Marginal Unsatisfactory Neutral

Performance meets/met 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/met 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/met 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/did 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/did 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.

FA9301-15-R-0009

mailto:Anthony.Trevino.2@us.af.mil mailto:Roberta.Ross@us.af.mil

CONTRACTOR’S NAME: __________________ CONTRACT NUMBER: _______________

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

The contractor: E G S M U N

1. Chemical toilets are placed, picked-up, and/or sanitized as scheduled.

2. Able to secure chemical toilets to withstand winds up to 70 miles per hour.

3. Submitted an effective quality control plan.

4. Provided effective quality control and/or inspection procedures to meet contract requirements during the contract period.

5. Followed Federal, State and local regulations and complied with safety requirements.

6. Corrected deficiencies in a timely manner and pursuant to their quality control procedures.

7. Identified problems as they occurred and suggested solutions.

8. Provided timely resolution of contract discrepancies.

9. Responsive to contract changes.

The contractor: E G S M U N

10. Provided adequate supervision.

11. Has successfully provided chemical toilets and hand wash stations for a special event with approximately 100,000 visitors per day.

12. Able to respond to emergency situation (including weekends) within 4 hours.

13. Hand wash stations are fully functional (to include water) supplied with paper towels and hand soap.

14. How would you rate the contractor's overall performance on this contract?

15. Septic Tanks are serviced within 24 hours of notification. YES/NO

16. Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks”. YES/NO

17. Would you award another contract to this contractor? If not, explain in “remarks”.

YES/NO

Remarks:______________________________________________________________________