PAST PERFORMANCE FORM.docx

HSSS01-12-Q-0064

PAST PERFORMANCE FORM

EXHIBIT A

Project title/location:

Name of Owner/Contracting Activity:

Date of Award:

Award value:

Contract value at completion if different from award amount:

Contracting Point of Contact & Telephone #:

Technical Point of Contact & Telephone #:

Brief Description of Project:

Problems encountered and corrective action taken:

Awards:

Project title/location:

Name of Owner/Contracting Activity:

Date of Award:

Award value:

Contract value at completion if different from award amount:

Contracting Point of Contact & Telephone #:

Technical Point of Contact & Telephone #:

Brief Description of Project:

Problems encountered and corrective action taken:

Awards:

PAST PERFORMANCE QUESTIONNAIRE

EXHIBIT B

The contractor listed below submitted a proposal in reference to solicitation HSSS01-12-Q-0064 and listed your company/agency as a reference. If you could provide the requested information, this will assist in making an accurate evaluation determination. Your comments are considered sensitive; therefore, you are advised that the Federal Acquisition Regulations (15.1004) prohibits the release of names of individuals providing reference information about an Offeror’s past performance. In order to maintain the integrity of the selection process, we respectfully request that you not divulge the name of the contractor nor discuss your comments on this questionnaire with any other individuals.

Please fax or e-mail this form to: Ms. Ericka Landry, e-mail Ericka.Landry@usss.dhs.gov; Fax 202-406-6801. E-mail is the preferred method.

Past Contract Information

1. Contractor:

2. Program Title/Contract Number:

Evaluator: (the following information will assist in the analysis of the data and is determined confidential)

1. Name:

Date:

2. Phone No.:

Fax No.:

3. Address:

4. Position held or function in relation to project:

Ratings:

Please evaluate the contractor’s performance using the following ratings:

Please rate and provide any supporting information for the following (use additional sheets as needed):

1. The relationship between the contractor and owner’s contract team.

Rating:

2. The contractor’s on-site management and coordination of subcontractors.

Rating:

3. The contractor’s overall corporate management, integrity, reasonableness and cooperative conduct.

Rating:

4. The contractor’s performance on delivery of quality work.

Rating:

5. The contractor’s quality control (CQC):

Rating:

6. The contractor’s ability to meet the performance schedule.

Rating:

7. What did the contractor do to improve schedule problems, if any?

Rating:

8. The contractor’s ability to provide the required work at a reasonable total price.

Rating:

9. The contractor’s compliance with labor standards, if applicable.

Rating:

10. The contractor’s compliance with safety standards and/or number of incidents.

Rating:

11. Has the contractor been given any of the following: Cure notice, show cause, letters of reprimand, suspension of payments, terminations? If yes, please explain.

Rating:

12.Would you award another contract to this contractor? If no, please state reasons for not recommending this contractor additional work.

Rating:

13. Was the customer satisfied with the end product?

Rating:

14. Has the contractor been provided an opportunity to discuss any negative performance ratings? If so, what were the results?

Rating:

15. Overall Rating:

Please provide any additional comments: