PastPerformanceQuestionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

NOTE: Offerors are responsible for requesting that their 3 references complete this past performance questionnaire. References shall return the completed questionnaire directly to the Domestic Dependent Elementary and Secondary Schools (DDDESS) Procurement Office, Not Later Than 16:00 PM (EST), 18 Nov 2011. References shall not return the completed questionnaires to the requestors.

You have been identified as having been a customer of the following company for providing Education Programs or similar services:

Requesting Company Name: ________________________________________________.

The Dept. of Defense Education Activity (DoDEA)/DDESS is conducting an evaluation of this company’s previous record of performance as part of a source selection process to award a contract for similar services. We cordially request you complete and forward this questionnaire:

To Arrive at DDESS Not Later Than: 16:00 PM (EST), 18 Nov 2011 to the DDESSPROC@am.dodea.edu, attention Michael J. Eadon. For questions related to this form, please contact Mr. Michael J. Eadon, Contract Specialist, at (678) 364-8061.

1. Company Information Name Street Address City State Zip Code

2. Point Of Contact (POC):

Name / Title Ph No. Fax No.

Email Address

3. Services Received:

Briefly Describe Services Received: ___________________________________________________ Country Where Services Performed: ______________ Approx. Value of Services: $____________ Date You Began Using This Firm’s Services: ______________

4. Rate the degree of service confidence received:

(Please rate services received by entering and “X” in the applicable rating block below)

1st Column = Subtstantial Confidence 2nd Column = Satisfactory Confidence 3rd Column = Limited Confidence 4th Column = No Confidence 5th Column = Neutral/Unknown Substant ial

Sat isfactory

Limi ted

No

Neutral

Effectiveness at providing Educational and Clinical assessments.

Responsiveness to the requirement and commitment to customer satisfaction.

Quality of workmanship

Experience, training and skill level of personnel accomplishing work.

Overall satisfaction with service/performance.

5. Please Provide Written Comments To Explain Your Ratings (Use Additional Sheets If Necessary):

6. Rated By:

Signature Printed Name & Title Date Domestic Dependent Elementary and Secondary Schools (DDESS), Procurement Division 700 Westpark Drive, Peachtree City GA 30269-3554