Past Performance Questionnaire.doc

PAST PERFORMANCE QUESTIONNAIRE

Please complete the following questionnaire and return by electronic mail to:

Joquita.pitt@dhs.gov This survey pertains to:

Department/Component:

Contract Number: ______________________Date of Survey: _______________

Name of Person Completing Survey:

Signature of Person Completing Survey:

Your Company/Agency:

Your role in this Contract (check one) :

( Contracting Officer

( Other

Contract Value (including options): $___________________________________

Performance Period: _______________________________________________

(Including Options)

Type of Contract: _________________________________________________

Approximate percentage of work being performed (or completed) by subcontractor(s): _______________%

PAST PERFORMANCE INFORMATION SURVEY

Information on subcontractor(s) (where the subcontractor completed more than

50% of work):

Subcontractor

Program Manager

Phone

General description of products/services required under the contract:

RATINGS

Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Commentary to support rating shall be noted on Page 4.

Assign each area a rating of 0 (Unsatisfactory), 1 (Poor), 2 (Fair), 3 (Good), 4 (Excellent), or 5 (Outstanding). Use the attached Rating Guidelines as guidance in making these evaluations. Circle the appropriate rating. If you do not have enough personal knowledge or feedback from internal customers who directly received products and services from the contractor to make a determination on any of the performance criteria below, please circle “N/A” (not applicable/no opinion).

QUALITY OF SERVICE

1. Compliance with contract requirements:

N/A

2. Accuracy of reports:

N/A

PAST PERFORMANCE INFORMATION SURVEY

3. Effectiveness of personnel:

4. Technical Excellence:

N/A

COST CONTROL (Not applicable to Fixed Price Type Contracts)

1. Record of forecasting and controlling target costs:

2. Current, accurate and complete billings:

3. Relationship of negotiated costs to actual:

4. Cost efficiencies:

N/A

TIMELINESS OF PERFORMANCE

1. Met interim milestones:

2. Reliability:

3. Responsive to technical direction:

4. Completed on time including wrap-up and contract administration:

5. Met delivery schedules:

N/A

6. Liquidate damages assessed: ( Yes ( No

PAST PERFORMANCE INFORMATION SURVEY

BUSINESS RELATIONS

1. Effective management, including management of subcontracts:

2. Reasonable/cooperative behavior:

3. Responsive to contract requirements:

4. Notification of problems:

5. Flexibility:

6. Pro-active vs. reactive:

N/A

SMALL BUSINESS AND SMALL DISADVANTAGED BUSINESS GOALS

1. The contractor met the goals set forth in its Subcontracting Plan. (See FAR 19.7 and 15.305(a)2(v):

( Yes

( No

( N/A

Comments (optional):

2. The contractor met Small Disadvantaged Business Participation goals. (See FAR 15.305(a)2(v) and FAR 19.1202):

( N/A

PAST PERFORMANCE INFORMATION SURVEY

CUSTOMER SATISFACTION

1. The contractor is committed to customer satisfaction:

2. Would you recommend selection of this firm again?

ADDITIONAL COMMENTS:

PAST PERFORMANCE INFORMATION SURVEY

RATING GUIDELINES

Billings

5-Outstanding: The contractor has demonstrated an outstanding performance level in any of the above four categories that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as "Excellent."

HSBP1009R2119