Attachment 4 - Past Performance Survey_TRANSS II.doc

ATTACHMENT 4

HTC711-12-R-R011

PAST PERFORMANCE SURVEY

When Filled In This Document Is Source Selection Sensitive

Information IAW FAR 3.104 & 2.101

A. GENERAL INFORMATION: (To be completed by Offeror) Offeror’s Name:_____ Address:_____

Telephone Number:_____ Email:_____ Point of Contact:_____ Project Title and Brief but Detailed Description of Work Performed by Offeror (including workload estimates):

Contract Number:_____ Contract Value (Base & Option Years): $_____ Place of Performance:_____ Period of Performance:_____ Contractor Performed as the_______Contractor (Identify Prime or Sub).

1) Identify the Type of Inspection Performed and the Annual Number of Inspections Performed:

a. Corporate Inspection:_____ Annual Number of Inspections Performed:_____

b. Facilities Inspection:_____ Annual Number of Inspections Performed:_____

c. In-Transit Inspection:_____ Annual Number of Inspections Performed:_____

d. Standards of Service and Safety Inspection:_____ Annual Number of Inspections

Performed:_____

2) Did the work require the offeror to have a Company Facility Clearance at the Secret level?_____

3) Did the work require inspectors to have a security clearance at the Secret level?_____

4) Did the work require the inspectors to be knowledgible of Department of Transportation (DOT), Department of Defense (DOD), state and local transportation regulations?_____ B. RESPONDENT INFORMATION (To be completed by Respondent):

Name of Respondent:_____

Title:_____ Address:____ Telephone Number:_____ Fax Number:_____

Email Address:

Note: If any of the information in Section A is incorrect, please make necessary changes. Also, if offeror holds or has held other relevant contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

C. E-MAIL OR FAX COMPLETED SURVEY FORM:

Please email or fax the completed survey to the below address no later than: 21 September 2012 by 4:00 PM Central Time to:

Fax:

USTRANSCOM/TCAQ-R

ATTN: Mr Belfield Collymore

Fax: 618-220-7918 Phone: 618-220-7038

Email:

belfield.collymore@ustranscom.mil and teresa.perry@ustranscom.mil Direct survey completion questions/comments to the above email address/individuals.

NOTE: Past Performance Information Retrieval System (PPIRS) may be reviewed. Although you may have filed a Contractor Performance Assessment Report (CPARS) for the contract listed, we would appreciate your response to this survey because some of the questions may relate to areas not covered by CPARS.

D. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2.

The contractor:

For large business concerns:

GENERAL

REMARKS:

Please provide a paragraph supporting your ratings above. Explain the contractor’s greatest strengths and/or weaknesses and your rationale why you would or would not award a future contract to them.

Survey Respondent’s Signature

Date

Thank you for your prompt response and assistance!