Past Performance Questionnaire.docx

M6700123Q0005 M6700123Q0005

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.

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.

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.

CONTRACTORS SHALL ONLY COMPLETE THIS PAGE

I. CONTRACT IDENTIFICATION:

A. CONTRACTOR NAME (being evaluated): ___________________________

PO Box/Street Address: ____________________________________________

City, State, & Zip: ________________________________________________

B. CONTRACT NUMBER:

Contract Award Date: _________________________________________________

Contract Completion Date :____________________________

Total Contract Amount: __________________________

C. DESCRIPTION OF CONTRACT

D. RELEVANCE OF WORK

II. IDENTIFICATION (Name of agency completing the evaluation form):

A. AGENCY NAME _ _______________________________________________________

PO Box/Street Address _______________________________________________________

City, State, & Zip _______________________________________________________

Point of Contact : _________________________________________________________

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.

[ ] Satisfactory [ ] Neutral [ ] 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.

[ ] Satisfactory [ ] Neutral [ ] 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.

[ ] Satisfactory [ ] Neutral [ ] 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).

[ ] Satisfactory [ ] Neutral [ ] 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.

[ ] Satisfactory [ ] Neutral [ ] Unsatisfactory

Comment:__________________________________________________________________________________________________________________________________________________________________

IV. SUMMARY OPINION. PLEASE “X” THE STATEMENT THAT BEST DESCRIBES YOUR EXPERIENCE WITH THE FIRM

a. ____ They were a SATISFACTORY firm. The contractor’s performance met contractual requirements.

b. ____ They were a NEUTRAL firm who were not observed during a contract’s period of performance.

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

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.