Attachment_L3_-_Past_Performance_Questionnaire.docx

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):

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.)

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.)

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?

N/A

2. QUALITY:

contract requirements

N/A

contract requirements

N/A

the specifications

N/A

control plan

N/A

3. TIMELINESS:

N/A

N/A

N/A

N/A

employees as required

N/A

N/A

4. RESPONSIVENESS:

requirements and safety regulations

N/A

as needed, and maintained communication with the government to keep the project on schedule or minimize delays

N/A

problems; displayed initiative to solve problems; and performed as a Team Member

N/A

contract

N/A

5. SUBCONTRACTS AND MANAGEMENT:

N/A

technical and administrative abilities needed to meet contract requirements

N/A

their work

N/A

subcontractors/suppliers

N/A

and take actions during project performance to keep the project on schedule

N/A

consistently present on site when work was performed

N/A

N/A

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104

NIHOF2016102

Attachment L3

SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104

6. DESIGN:

project

N/A

design

N/A

were designed

N/A

7. CHANGE/COST CONTROL:

supportable cost proposals

N/A

modifications within the magnitude specified

N/A

Government

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