Attachment 12 - PastPerformanceQuestionnaire.doc

HSCG84-12-R-BHQ003

PAST PERFORMANCE QUESTIONNAIRE

SOURCE SELECTION INFORMATION (FAR 3.104)

Please Return E-Mail or FAX to: U.S. Coast Guard, Emely Hagins, Contract Specialist

Email: emely.hagins@uscg.mil Tel: (510) 437-3057 Fax: (510) 437-3014

U.S. COAST GUARD

SHORE INFRASTRUCTURE AND LOGISTIC CENTER

PAST PERFORMANCE QUESTIONNAIRE

Solicitation Number: HSCG84-12-R-BHQ003 Name of evaluated firm: __________________________________________________ To Reference Organization: In accordance with the Government’s increased emphasis on past performance and experience as an evaluation factor, the U. S. Coast Guard is hereby requesting past performance and experience information on the above-listed firm that has listed you as a reference for the above Solicitation. The successful offeror will be required to fabricate and deliver Foam-filled Steel River Buoys.

Please complete the following Questionnaire and e-mail or FAX to the Coast Guard only at the above address.

Please do not send a copy to the firm.

( Thanking you in advance for taking the time to complete this survey and returning to the Coast Guard quickly but no later than TBD.

CONTRACTOR PERFORMANCE QUESTIONNAIRE

A. IDENTIFICATION

1. Respondent Organization Name:

2. Address:

3. Phone Number:

Fax Number:

E-Mail:

4. Name & Title of Evaluator:

5. Contract/Subcontract Number:

6. Contract/Subcontract Amount (including all options):

7. Contract Type: FFP

Cost Reimbursable

Other (specify)

· Competitive ( ) Noncompetitive ( )

8. Period of Performance (including options, if applicable)

B. CONTRACT INFORMATION

NOTE: When indicated please circle the appropriate score, and for scores below or above Acceptable, please provide detailed comments, citing specific examples.

Relevancy: Contracts of similar type, service, duration, and dollar value.

a. Type of Services Provided:

b. Contract Total Dollar value:

COMMENTS:____________________________________________________________

C. ASSESSMENT

1. Product Quality Did the Offeror provide a quality product in terms of conforming to the contract requirements AND WORKMANSHIP?

Rating: Exceptional Acceptable Marginal Unsatisfactory

COMMENTS:______________________________________________________________

2. Timeliness Did the Offeror adhere to contract schedules? Has the offeror responded in a credible manner to emergency service requirements?

Rating: Exceptional Acceptable Marginal Unsatisfactory

COMMENTS:______________________________________________________________

3. Business Practices Did the offeror display reasonable business practices? Did the offeror exhibit a cooperative behavior?

Rating: Exceptional Acceptable Marginal Unsatisfactory

COMMENTS:______________________________________________________________

4. Cost Control Did the offeror exhibit good cost control practices? (Note: This first question does not apply to firm-fixed-price contracts) What is the contractor’s history on contract change proposals? This would include changes that lower the overall cost or improve performance – timely and accurate proposals for equitable adjustments – changes that have been withdrawn or dismissed as invalid.

Rating: Exceptional Acceptable Marginal Unsatisfactory

COMMENTS:______________________________________________________________

5. Customer Satisfaction Was the Offeror committed to customer satisfaction and did the offeror display a business-like concern for the interest of the customer? Would you award another contract to this offeror?

Rating: Exceptional Acceptable Marginal Unsatisfactory

COMMENTS:______________________________________________________________

END OF SURVEY

Attachment 12