Past_Performance_Questionnaire.pdf

M6700117Q0038

PAST PERFORMANCE QUESTIONNAIRE FORM

This is a survey to evaluate Contractor’s performance indicated on page two of the survey.

The survey contains a series of evaluation elements and questions asking you, as the evaluator, to provide an evaluation of the contractor’s performance. Using the rating level definitions below, please provide a rating level for each element that best describes the contractor’s performance.

Please respond to each question by answering yes or no and providing explanations as appropriate.

Please provide frank and concise comments in your evaluation and assessment of contractor performance.

In addition to responding to the given statements and questions for the contract listed, please provide other information or knowledge of contractor performance for similar contracts performed by the contractor for your organization.

Rater Information. After completing the survey, please provide the requested rater information and sign/date the survey.

Offeror shall submit Past Performance Reference informaiton with quote/proposal.

Rating Level Descriptive Definition

Exceptional

The contractor’s performance meets contractual requirements and exceeds many 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

The contractor’s performance meets contractual requirements and exceeds some 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

The contractor’s 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

The contractor’s 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. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory

The contractor’s 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 problems for which the contractor’s corrective actions appear or were ineffective.

Neutral

Not observed under this contract.

I. CONTRACT IDENTIFICATION:

A. CONTRACTOR NAME: _________________________

PO Box/Street Address: ___________________________

City, State, & Zip: _______________________________

B. CONTRACT NUMBER

Contract Award Date: _______________________

Contract Completion Date :___________________

Total Contract Amount: ______________________

Contract Method [ ] Request for Quote [ ] Negotiated [ ] Sealed Bid Competitive [ ] Yes [ ] No Type of Contract [ ] Fixed Price [ ] Cost Reimbursement Other (Specify): __________________________

C. DESCRIPTION OF CONTRACT

D. RELEVANCE OF WORK

II. IDENTIFICATION:

(NAME OF PERSON AND AGENCY OR COMPANY COMPLETING THE

QUESTIONNAIRE)

A. AGENCY NAME _______________________________________

PO Box/Street Address _______________________________________

City, State, & Zip ________________________________________

Evaluator Name: ________________________________________

III. PAST PERFORMANCE EVALUATION:

A. QUALITY OF PRODUCT OR SERVICE. Compliance with contract requirements, technical excellence of proposed supply items and service(s), furnished documents and reports in an accurate and timely manner.

[ ] Exceptional [ ] Very Good [ ] Satisfactory [ ] Marginal [ ] Unsatisfactory

Comment:_____________________________________________________________________________

Was consideration or a monetary with held for non-conforming supplies/services or late deliveries against this contract? Yes ___ No ___

If yes explain ___________________________________________________________________________

Was any part if the contract terminated or in litigation? Yes _____ No _____

If yes explain ___________________________________________________________________________

Did the contractor receive any quality awards in performance of the contract? Yes _____ No _____

List awards, if applicable:_________________________________________________________________

Did the contract have option periods for performance. Yes _____ No _____

If yes, were all options exercised? Yes _____ No _____

If not, please explain_____________________________________________________________________

Did the firm comply with all environmental aspects of the contract? Yes _____ No ____

Additional Explanation ___________________________________________________________________

B. TIMELINESS OF PERFORMANCE. Met service(s) performance times and did not receive any cure and/or show cause notices or have numerous complaints.

[ ] Exceptional [ ] Very Good [ ] Satisfactory [ ] Marginal [ ] Unsatisfactory

Comment:_____________________________________________________________________________

Were all items (including products, services, reports, etc) delivered within original contract schedule?

Yes ____ No ____

If no explain: ___________________________________________________________________________

Describe any corrective actions initiated to solve any of the above problems.

C. COST CONTROL. Pricing was considered Satisfactory and reasonable, no excessive or unreasonable claims and submits proper invoices.

[ ] Exceptional [ ] Very Good [ ] Satisfactory [ ] Marginal [ ] Unsatisfactory

Comment:___________________________________________________________________________

Did the contractor perform this contract at the original contract price? Yes ____ No ____

Did the contractor request any kind of equitable adjustment in performance of this contract?

Yes ____ No ____

If yes explain ___________________________________________________________________________

D. CUSTOMER (end user) SATISFACTION. Customer (end-user) satisfaction of overall performance for contract service(s).

[ ] Exceptional [ ] Very Good [ ] Satisfactory [ ] Marginal [ ] Unsatisfactory

Comment:___________________________________________________________________________

E. BUSINESS RELATIONS. Effective Management, reasonable and cooperative behavior and overall business-like concern for the interests of the customer, effective Contractor recommended solutions to problems.

[ ] Exceptional [ ] Very Good [ ] Satisfactory [ ] Marginal [ ] Unsatisfactory

Comment:_____________________________________________________________________________

IV. SUMMARY OPINION. PLEASE “X” THE STATEMENT THAT BEST DESCRIBES

YOUR EXPERIENCE WITH THE FIRM

a. ____ They were an EXCEPTIONAL firm in every respect. Problems were solved in a spirit of teamwork. Quality work, timely actions and complete documentation were routinely achieved. We would unhesitatingly do business with the firm again.

b. ____ They were a VERY GOOD firm who met the minimum requirements of the contract.

Performance deficiencies improved when identified. An aggressive inspection program was required to ensure compliance. We would do business with the firm again.

c. ____ They were a MARGINAL firm who barely met the minimum requirements of the contract.

We have serious doubts about doing business with this firm again.

d. ____ They were a UNSATISFACTORY firm who did not meet the requirements of the contract.

We would not want to do business with this firm again under any circumstances.

e. ____ None of the above statements describes the firm. The following statement best describes our experience with them:

EVALUATOR’S CERTIFICATION

I HEREBY CERTIFY THAT THE INFORMATION ON THIS FORM IS ACCURATE AND

COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE OF EVALUATOR PRINTED NAME OF EVALUATOR

TITLE OF EVALUATOR DATE