Attachment_L3_Past_Performance_Questionnaire.pdf

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104

NIHOF2013536

Attachment L3

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104 1

Past Performance Questionnaire

PART A – CONTRACTOR INFORMATION (to be completed by the contractor requesting evaluation prior to mailing)

A. Contractor’s name and address: _____________________________________________________________

B. Contractor’s point of contact: ______________________________________________________________

C. Phone number (with area code): ____________________________________________________________

D. Contract Number: _______________________________________________________________________

E. Project Title: ___________________________________________________________________________

F. Work Type (choose one): ____ Design-Build ____ Construction Only

G. Project Award Amount: $______________________ Final Project Amount: $________________________

H. Contractor performed as the (select one): ____ Prime Contractor ____ Joint Venture ____ Subcontractor

I. List all Major Subcontractors (performed more than 5% of the work):

Name of the Firm Work Performed Subcontract Amount Point of Contact Phone

Designer $

J. Authorization is hereby granted to provide the information requested in PART B of this Questionnaire.

(Signature)

(Name and Title of Authorizing Official) (Date)

PART B – SECTION 1: RESPONDENT INFORMATION (to be completed by the evaluator)

A. Organization’s name: _____________________________________________________ Date: ______________________________

B. Evaluator’s name and title: ___________________________________________________________________________________

C. Evaluator’s contact information (phone and email): ________________________________________________________________

D. Number of years and relationship of evaluator to the subject contract: __________________________________________________

E. Description of Work performed under this project: _________________________________________________________________

F. Project Award Date: _____________________________ Original Contract Completion Date: _______________________________

Final Contract Completion Date: ___________________ Turnover/Acceptance Date: ______________________________________ Please explain any differences between the Original, Final, and/or Turnover dates: __________________________________________

G. Has a Contract Performance Evaluation been submitted and accepted for the project identified in Part A (yes/no)? _______________ (If YES then a copy of the evaluation may be submitted in lieu of this Questionnaire.)

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104 2

PART B – SECTION 2: PERFORMANCE INFORMATION (Choose the letter on the scale that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OTHER THAN SATISFACTORY

IN THE REMARKS SECTION.)

U M S O N/A

Unsatisfactory Marginal Satisfactory Outstanding Not applicable

Based on the contractor’s performance record, the contractor did not successfully perform the required effort.

Based on the contractor’s performance record, the contractor was somewhat successful in performing the required effort.

Based on the contractor’s performance record the contractor successfully performed the minimum required effort.

Based on the contractor’s performance record the contractor was highly successful in performing the required effort.

No or very limited performance information is available therefore no meaningful rating can be reasonably assigned.

Evaluation Areas

1. CUSTOMER SATISFACTION:

Would you have any reservations in awarding another contract to this Contractor or working with this Contractor on any future contracts? YES NO N/A

2. QUALITY:

a Contractor provided effective quality control and/or inspection procedures to meet contract requirements U M S O N/A b Contractor provided well researched and clearly identified submittals that matched contract requirements U M S O N/A c Contractor completed all work with good workmanship and in conformance with the specifications U M S O N/A d Contractor corrected deficiencies in a timely manner and pursuant to their quality control plan U M S O N/A

3. TIMELINESS:

a Contractor met established project milestones without excessive revisions U M S O N/A b Contractor provided timely cost/design proposals U M S O N/A c Contractor submitted adequate progress schedules and progress reports as required U M S O N/A d Contractor provided on-time submittals as required U M S O N/A e Contractor provided payrolls for both their employees and their subcontractors employees as required U M S O N/A f Contractor provided timely resolution of all punch list items U M S O N/A

4. RESPONSIVENESS:

a Contractor acted promptly to resolve problems, ensuring compliance with contract requirements and safety regulations U M S O N/A b Contractor was reasonable and cooperated to resolve problems, attended meetings as needed, and maintained communication with the government to keep the project on schedule or minimize delays

U M S O N/A c Contractor identified problems as they occurred; suggested approaches to the problems; displayed initiative to solve problems; and performed as a Team Member

U M S O N/A d Contractor responded to warranty issues within the time frames specified in the contract U M S O N/A

5. SUBCONTRACTS AND MANAGEMENT:

a Contractor successfully partnered with all stakeholders to meet contract objectives U M S O N/A b Contractor provided experienced/qualified managers and supervisors with the technical and administrative abilities needed to meet contract requirements U M S O N/A c Contractor hired quality subcontractors and effectively managed and coordinated their work U M S O N/A d Contractor hired, maintained, and replaced as necessary, qualified personnel and subcontractors/suppliers U M S O N/A e Contractor ensured the project manager had sufficient authority to make decisions and take actions during project performance to keep the project on schedule U M S O N/A f Contractor ensured site superintendent and quality control representative were consistently present on site when work was performed U M S O N/A g Contractor paid employees/subcontractors/suppliers as required U M S O N/A

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104 3

6. DESIGN:

a Contractor provided complete, supportable, technically sound designs for the project U M S O N/A b Contractor demonstrated the ability to incorporate user’s requirements into the design U M S O N/A c Contractor completed designs that were constructed in the same manner as they were designed U M S O N/A

7. CHANGE/COST CONTROL:

a Contractor responsive to contract changes and provided accurate, reasonable and supportable cost proposals U M S O N/A b Contractor demonstrated the ability to control costs and/or design projects or modifications within the magnitude specified U M S O N/A c Contractor validated subcontractor cost proposals prior to submission to the Government U M S O N/A

PART B – SECTION 3: REMARKS

1. Customer Satisfaction – Please explain your response to Question 1 above:

2. Quality:

3. Timeliness:

4. Responsiveness:

5. Subcontracts and Management:

6. Design:

7. Change/Cost Control:

PART B – SECTION 4: GOVERNMENT CONTRACTS ONLY

Was the contractor ever issued a cure or show cause notice under the referenced contract? No Yes If yes, explain the outcome: ______________________________________________________________________________________

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing address: National Institutes of Health

ATTN: Daniel F. Burk 111 T.W. Alexander Drive Research Triangle Park, NC 27009

Or Email: Daniel.Burk@nih.gov