Past_Performance_Survey.docx
DOCX document 24 KB Posted
- Attached to
- NJ-EDWIN B FORSYTHE NWR-GATE INSTALL
- Solicitation number
- 140FS326Q0029
About this file
This is a Past Performance Survey template used to collect historical contract information from companies bidding on federal opportunities. The form requests general business information including company name, address, date of organization, organizational structure (partnership, separate entity, or division), company leadership, and SAM.gov Unique Entity Identifier (UEI).
The survey requires detailed documentation of up to three completed or in-progress contracts or subcontracts, with government contracts being preferred. For each contract listed, respondents must provide the contracting agency or company name, point of contact, telephone number, contract number, contract amount, project title and location, general scope of work, the company's role (prime contractor, joint venture partner, or subcontractor), subcontract details including total subcontract amounts, period of performance, scheduled and actual completion dates, percentage of work completed, and termination status. Additionally, companies must document whether quality control and safety plans were implemented, describe any quality control or safety problems encountered, and explain how problems were resolved. The form concludes with a certification section requiring the signature, printed name, title, phone number, email address, and date from the survey preparer. This template is associated with solicitation 140FS326Q0029 for the Edwin B. Forsythe National Wildlife Refuge Gate Installation project issued by the Department of the Interior Fish and Wildlife Service.
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Text version
PAST OR PRESENT PERFORMANCE SURVEY
Your Company Name:
Street Address:
City, State and ZIP Code:
1. GENERAL BUSINESS INFORMATION
Date Firm Organized/Established:
| Company President: | Vice President: | |
| SAM.gov Unique Entity Identifier (UEI): | __ |
Is company a ; Partnership [ ] Separate entity [ ] Division [ ] N/A [ ]
2. CONTRACTS/SUBCONTRACTS COMPLETED OR IN PROGRESS
Complete and submit the information requested on page 2-4 below on prime contracts or subcontracts completed or in progress. Government contracts are preferred; but, if you have not performed Government contracts, indicate any other contracts completed or in progress.
a. First Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $ Period of Performance: days Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Did you use a Quality Control Plan? _________ Did you use a Safety Plan?_______________
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
b. Second Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
c. Third Contract:
Contracting Agency or Company:
| Point of Contact: | Telephone Number: | ||
| Contract Number: | Contract/Subcontract Amount: $ | _____ |
Project Title and Location:
General Scope of Project: ____________
Your Role (Prime [ ], Joint Venture [ ], or Subcontractor [ ]) and the work your firm performed:
Describe any Work You Subcontracted to Others:
Total Amount of Subcontract(s): $
Scheduled Completion Date:
Actual Completion Date: Percentage of Work Completed: % Were You Terminated?
Quality Control or Safety Problems encountered (if any):
How were the problems resolved? _____
Type or Print Information Name of Survey Preparer
Phone:_________________ E-Mail;___________________________ Title Signature Date )4. Certification of Past Performance Information:
File details come from the government source that posted it. Updated .