Past_Performance_Survey.docx
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- Attached to
- VA DIV OF BIRD HAB CONSRV DUCK STAMP AV
- Solicitation number
- 140FS326Q0066
About this file
This is a Past or Present Performance Survey form used to document a company's contract history and experience. The survey requests comprehensive information about the submitting company's organizational details, including the company name, address, date established, and leadership contacts, along with the company's SAM.gov Unique Entity Identifier and business structure classification.
The form requires companies to detail up to three completed or in-progress contracts or subcontracts, whether from government or commercial sources. For each contract, respondents must provide the contracting agency or company name, point of contact information, contract number, and contract amount. Additional required details include the project title and location, general scope of work, the company's role as a prime contractor, joint venture partner, or subcontractor, and any work subcontracted to others with corresponding amounts. The survey also captures performance metrics such as the period of performance, scheduled and actual completion dates, percentage of work completed, and termination status. Quality assurance and safety elements are addressed, requiring documentation of whether quality control and safety plans were implemented and any problems encountered during contract execution, along with how such problems were resolved. The form concludes with a certification section for the survey preparer's signature, including their name, title, phone number, email, and date of submission.
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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 .