JWH_Attachment_V__Past_Performance_Risk_Assessment_Questionnaire.doc

ATTACHMENT V – PAST PERFORMANCE RISK ASSESSMENT QUESTIONNAIRE

FOR REQUEST FOR QUOTE NIHES2017101

JOURNAL WEB HOSTING – ENVIRONMENTAL HEALTH PERSPECTIVES

NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES

RESEARCH TRIANGLE PARK, NORTH CAROLINA

Please provide your candid responses. The information that you provide will be used in the awarding of federal a Federal contract. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does.

PART I. GENERAL INFORMATION (To be completed by the Quoter) A. Contract Identification

1. Contractor/Company Name/Division:

2. Company Address:

3. Project Title:

4. Contract Number:

5. Contract Type:

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

7. Contract Award:

8. Forecasted or Actual Contract Completion Date:

9. Description of the Services:

B. Identification of Quoter’s Representative

1. Name:

2. Title:

3. Date:

4. Telephone Number:

5. E-mail Address:

C. Reference’s Identification

1. Organization:

2. Name:

3. Title:

4. Telephone Number

5. E-mail Address:

PART II. EVALUATION (To be completed by Point of Contact – Reference) A. Compliance of Products, Services, Documents, and Related Deliverables to Specification Requirements and Standards of Good Workmanship.

FORMCHECKBOX

Exceeds Contractual Requirements (Explanation must be provided in Comments field below)

FORMCHECKBOX

Meets Contractual Requirements

FORMCHECKBOX

Failed to Meet Contractual Requirements (Explanation must be provided in Comments field below) Comments:

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

FORMCHECKBOX

Exceptional (Explanation must be provided in Comments field below)

FORMCHECKBOX

Satisfactory

FORMCHECKBOX

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

C. Timeliness of Performance for Services and Product Deliverables, including the Administrative Aspects of Performance.

FORMCHECKBOX

Exceeds Contractual Requirements (Explanation must be provided in Comments field below)

FORMCHECKBOX

Meets Contractual Requirements

FORMCHECKBOX

Failed to Meet Contractual Requirements (Explanation must be provided in Comments field below) Comments:

D. Overall Satisfaction.

FORMCHECKBOX

Extremely Satisfactory (Explanation must be provided in Comments field below)

FORMCHECKBOX

Satisfactory

FORMCHECKBOX

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

E. General Comments: Please provide any other relevant performance information below:

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

PART III. RETURN INFORMATION

When completed, please return via e-mail to the Quoter so the questionnaire may be compiled with others in the submission of Request for Quote NIHES201700104.

Thank you for your assistance.