PastPerformanceQuestionnaire(Atch6 RFPFA5685-08-R-0001).doc

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FOR OFFICAL USE ONLY

RFP FA5685-08-R-0001

ATTACHMENT 4 - PAST PERFORMANCE QUESTIONNAIRE

Source Selection Document

1.a. Project Name and Location:

1.b. Mark involvement for this project (Check the one that applies): (If other, describe in Block 26)

Prime Contractor Sub-Contractor Joint Venture Other

2. Project owner’s complete address:

3a. Technical Point of Contact for project

(Name, title, address, phone, fax, email):

4b. Contracting Point of Contact for the project

(Name, title address, phone, fax, email):

4. Describe contract type (Major/Minor Repair, Renovation, Construction, etc), Nature and Scope of work:

4a. Current Status of Project (Check the one that applies):

Work continuing, on schedule (must be greater than 50% complete)

Work continuing, behind schedule

Work completed, no further action pending

Work completed, routine administrative action pending Work completed, claims negotiation pending/underway

Work completed, litigation pending/underway

Terminated for convenience

Terminated for default

Other (explain in Block 26, Additional Comments)

5. Date work was begun (Day/Month/Year):

6. Date work was completed (Day/Month/Year):

Estimated Date of Completion: / / Actual Date of Completion*: / /

*leave blank if project is ongoing

7. If actual completion date is later than initial completion date, explain why:

8. Initial contract price

Amount for which Offeror was responsible:

$ _________________.00

9. Final invoiced amount (or amount invoiced to date)

Amount for which Offeror was responsible:

$ _________________.00

10. If final invoiced amount greater than initial contract amount, explain why:

11. Project Name and Location:

12. Explain any problem(s) encountered, and solution to resolve problem(s):

13. Were there any safety problems or accidents? Explain:

Provide, based on the job description, the names of the following personnel that worked on this project in following positions:

(Check the one that applies):

26. Additional Comments:

Please attach any Letters of Appreciation that apply ONLY to this project to this form.

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