Attachment_5_Past_Performance.pdf

Your assistance is requested in support of a source selection.

Please complete this Questionnaire and Email to :

Contracting Office Address:

Attn:

Desired Response Date:

When complete, the information on this form is SOURCE SELECTION SENSITIVE INFORMATION (41 U.S.C. 423) and shall be protected accordingly.

TO BE COMPLETED BY OFFEROR

1. CONTRACTOR NAME & ADDRESS: 2. CONTRACT NO.:

Ctrl+Enter for next line

3. CONTRACT INITIATION DATE:

4. COMPLETION DATE:

5. CONTRACT VALUE (with options): $

6. TYPE OF CONTRACT:

7. DESCRIPTION OF CONTRACT REQUIREMENTS:

Contractor performed as Prime on contract listed above Contractor performed as Subcontractor on contract listed above Please add a continuation page if additional space necessary.

TO BE COMPLETED BY EVALUATING ORGANIZATION REPRESENTATIVE

8. EVALUATION: a. EVALUATOR'S NAME, POSITION (Project Manager/ COR/ Other) AND ORGANIZATION:

b. EVALUATOR'S PHONE NUMBER: c. MONTHS PERFORMANCE MONITORED BY EVALUATOR:

Please check the response code for each topic (A – F) that best reflects your experience with this contractor.

O = Outstanding E = Excellent

A = Adequate M = Marginal

P = Poor N/O = Not Observed

A. Quality of Products and Services - Assess the contractor's conformance to contract requirements, specifications, and standards of good workmanship (e.g., technical, professional, environmental, or safety and health standards).

O E A M P N/O

B. Performance - Assess the contractor's performance as the General Contractor or Architect/Engineer (as appropriate) for the project.

O E A M P N/O

C. Schedule - Assess the timeliness of contractor against the schedule of activities.

O E A M P N/O

D. Technical Requirements - Assess the contractor's ability to fulfill the technical requirements of the contract.

O E A M P N/O

E. Customer Satisfaction - Assess the contractor's responsiveness to customer concerns and “user friendliness”.

O E A M P N/O

F. Assess Overall extent that you would do business with this company again.

1 2 3 4 5 Highest Lowest

Attachment:

PERFORMANCE QUESTIONNAIRE

Comments:

Your assistance is requested in support of a source selection.

Please complete this Questionnaire and Email to :

Contracting Office Address:

Attn:

Desired Response Date:

When complete, the information on this form is SOURCE SELECTION SENSITIVE INFORMATION (41 U.S.C. 423) and shall be protected accordingly.

TO BE COMPLETED BY OFFEROR

1. CONTRACTOR NAME & ADDRESS:

2. CONTRACT NO.:

Ctrl+Enter for next line

3. CONTRACT INITIATION DATE:

4. COMPLETION DATE:

5. CONTRACT VALUE (with options): $

6. TYPE OF CONTRACT:

7. DESCRIPTION OF CONTRACT REQUIREMENTS:

Contractor performed as Prime on contract listed above Contractor performed as Subcontractor on contract listed above Please add a continuation page if additional space necessary.

TO BE COMPLETED BY EVALUATING ORGANIZATION REPRESENTATIVE

8. EVALUATION: a. EVALUATOR'S NAME, POSITION (Project Manager/ COR/ Other) AND ORGANIZATION:

b. EVALUATOR'S PHONE NUMBER: c. MONTHS PERFORMANCE MONITORED BY EVALUATOR:

Please check the response code for each topic (A – F) that best reflects your experience with this contractor.

O = Outstanding E = Excellent A = Adequate M = Marginal P = Poor N/O = Not Observed A. Quality of Products and Services - Assess the contractor's conformance to contract requirements, specifications, and standards of good workmanship (e.g., technical, professional, environmental, or safety and health standards).

O E A M P N/O B. Performance - Assess the contractor's performance as the General Contractor or Architect/Engineer (as appropriate) for the project.

O E A M P N/O C. Schedule - Assess the timeliness of contractor against the schedule of activities.

O E A M P N/O D. Technical Requirements - Assess the contractor's ability to fulfill the technical requirements of the contract.

O E A M P N/O E. Customer Satisfaction - Assess the contractor's responsiveness to customer concerns and “user friendliness”.

O E A M P N/O F. Assess Overall extent that you would do business with this company again.

Highest Lowest

PERFORMANCE QUESTIONNAIRE

{Insert Project Name} RFQ

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6/30/2009 12:59:00 PM

PRPO

48640 -999208599 Past Performance Question sample valerie.green@whs.mil Green, Valerie CIV WHS/A&PO -1008262760

6/30/2009 12:59:00 PM