J007 - Past Performance Evaluation Questionnaire Form.pdf

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

To be completed and e-mailed to the Contract Specialist and

Contracting Officer

See Proposal Preparation Instructions in the Instructions to

Proposers Section of the Solicitation

Contractor:____________________ Contract No.:____________________________

Subcontract No. (if applicable):_________________________________

POC:________________________ Title:________________________

(Name) (E.G. PCO/ACO/TM)

(Agency, Telephone No., E-mail Address & Fax Number)

The following questions pertain to the contractor’s record of past (within the past five years) and current performance. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that our information be as factual and accurate as possible. Please provide examples and/or explanations (use additional pages if necessary). The following ratings shall be used in your response.

EXCEPTIONAL – Performance meets contractual requirements and exceeds many

(requirements) to the Government’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

VERY GOOD – Performance meets contractual requirements and exceeds some

(requirements) to the Government’s benefit. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

SATISFACTORY – Performance meets contractual requirements. The contractual performance of the element being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

MARGINAL – Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

PART I. (To be completed by the Offeror)

A. CONTRACT IDENTIFICATION

Contractor/Company Name/Division:

Address:

Program Identification/Title:

Contract Number:

Contract Type:

Prime Contractor Name (if different from the contractor name cited above):

Contract Award Date:

Forecasted or Actual Contract Completion Date:

Nature of the Contractual Effort (Must be related to Courtroom Remodel):

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE

Name:

Title:

Date:

Telephone Number:

Address:

E-mail Address:

PART II. EVALUATION (To be completed by Point of Contact – Respondent)

A. Compliance of Products, Services, Documents, and Related Deliverables to

Specification Requirements and Standards of Good Workmanship

Exceptional (Explanation must be provided in Comments field below)

Very Good

Satisfactory

Marginal (Explanation must be provided in Comments field below)

Unsatisfactory (Explanation must be provided in Comments field below)

Comments:

B. Effectiveness of Project Management (to include use and control of subcontractors).

Exceptional (Explanation must be provided in Comments field below)

Very Good

Satisfactory

Marginal (Explanation must be provided in Comments field below)

Unsatisfactory (Explanation must be provided in Comments field below)

Comments:

C. Timeliness of Performance.

Exceptional (Explanation must be provided in Comments field below)

Very Good

Satisfactory

Marginal (Explanation must be provided in Comments field below)

Unsatisfactory (Explanation must be provided in Comments field below)

Comments:

D. Commitment to Customer Satisfaction and Business-like Concern for its

Customers’ Interest

Exceptional (Explanation must be provided in Comments field below)

Very Good

Satisfactory

Marginal (Explanation must be provided in Comments field below)

Unsatisfactory (Explanation must be provided in Comments field below) must be provided in Comments field below)

Comments:

E. General Comments. Provide any other relevant performance information.

F. Other Information Sources. Please provide the following information:

Are you aware of other relevant past efforts by this company?

If yes, please provide the name and telephone number of a point of contact:

G. Respondent Identification. Please provide the following information:

Organization:

Name:

Title:

Date:

Telephone Number

Address:

E-mail Address:

PART III. RETURN INFORMATION

Thank you for your assistance.

Signature Date

Typed or Printed Name