Attachment F - Past Performance Questionnaire.pdf

Contractor Past Performance Questionnaire

CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information

Firm Name: ________________________________________________ UEI:________________

Address: __________________________________________________

Phone Number: ____________________________________________

Email Address: _____________________________________________

Point of Contact: ___________________________________________ Phone Number: ____________

2. Work Performed as Prime Contractor Subcontractor Joint Venture

Percent of project work performed: _______________________________________________________

If subcontractor, who was the Prime (Name/Phone#): ________________________________________

3. Contract Information

Contract Number: ______________________________________________________________________

Delivery/Task Order Number (if applicable): _________________________________________________

Contract Type: Firm Fixed-Price Cost Reimbursement Other (Please Specify) _____________

Contract Title: _________________________________________________________________________

Contract Location: _____________________________________________________________________

Award Date: _________________________ Contract Completion Date _______________________

Actual Completion Date (If Different from Contract Completion Date): ____________________________

Explain:

4. Project Description:

Complexity of Work High Medium Routine

How is this project relevant to project submission? (Please provide details such as similar equipment, requirements, conditions, etc)

CLIENT INFORMATION (Client to complete Blocks 5-8)

5. Client Information:

Name: _______________________________________________________________________________

Title: ________________________________________________________________________________

Phone Number: ________________________________________________________________________

Email Address: ________________________________________________________________________

6. Describe the client’s role in the project:

7. Date Questionnaire was Completed:

8. Client’s Signature: ___________________________________

NOTE: Phoenix Area Indian Health Service (PAIHS) requests that the client completes this questionnaire and submits directly back to the offeror. The offeror will submit the completed questionnaire to IHS with their quote/proposal/bid and may duplicate this questionnaire for future submission on PAIHS solicitations. Please contact the offeror for PAIHS POC information. The Government reserves the right to verify any and all information on this form.

ADJECTIVE RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT YOUR EVALUATION OF THE

CONTRACTOR’S PERFORMANCE

RATING DEFINITION NOTE

(E) Exceptional

Performance meets contractual requirements and exceeds many for the government/owner’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

An Exceptional rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the Government/owner. A singular benefit, however, could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

(VG) Very Good

Performance meets contractual requirements and exceeds some of them to the government’s/owner’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

A Very Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the government/owner. There should have been NO significant weaknesses identified.

(S) Satisfactory

Performance meets minimum contractual requirements. The contractual performance of the elements or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified.

(M) Marginal

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

A Marginal rating is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government/owner.

(U) Unacceptable

Performance does not meet most contractual requirements and recover is not likely in a timely manner. The contractual performance of the element or sub-element contains serious a problem(s) for which the contractor’s corrective actions appear to be or were ineffective.

An Unsatisfactory rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the government/owner. A singular problem, however, could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

(N) Neutral No information or did not apply to your contract.

NA rating will neither be positive nor negative.

TO BE COMPLETED BY CLIENT

PLEASE SELECT THE ADJECTIVE RATING WHICH BEST REFLECTS YOUR EVALUATION OF THE

CONTRACTOR’S PERFORMANCE.

1. QUALITY:

a) Quality of technical performance E VG S M U N

b) Ability to meet quality standards specified for technical performance

E VG S M U N

c) Effectiveness of contract problem resolution without extensive customer guidance

E VG S M U N

d) Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements

E VG S M U N

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

a) Compliance with contract delivery/completion schedule, including any significant intermediate milestones. (If liquidated damages were assessed or the schedule was not met, please address below)

E VG S M U N

b) Contractor’s use of available resources to accomplish tasks identified in the contract E VG S M U N

3. CUSTOMER SATISFACTION:

a) End user satisfaction with the project E VG S M U N

b) Contractor was reasonable and cooperative in dealing with government staff (Including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, and appropriate communication)

E VG S M U N

c) Contractor’s level of concern and responsiveness to customer concerns

E VG S M U N

d) Overall customer satisfaction E VG S M U N

4. MANAGERMENT/PERSONNEL/LABOR

a) Effectiveness of on-site management, including management of subcontractors, suppliers, materials, and/or labor force

E VG S M U N

b) Ability to hire, apply, and retain a qualified workforce to this effort.

E VG S M U N

c) Government Property Control E VG S M U N

d) Knowledge/expertise demonstrated by contractor personnel

E VG S M U N

e) Utilization of Small Business Concerns (sub-contracting)

E VG S M U N

f) Ability to manage concurrent projects with multiple disciplines.

E VG S M U N

g) Ability to assimilate and incorporate changes in requirements and/or priority, including planning execution and response to Government changes

E VG S M U N

h) Effectiveness of overall management (including ability to effectively lead, manage and control the program)

E VG S M U N

5. COST CONTROL/FINANCIAL MANAGEMENT

a) Ability to meet the terms and conditions within the contractually agreed price(s)

E VG S M U N

b) Contractor proposed innovative alternative methods/processes that reduced cost, improved maintainability or other factors that benefited the client

E VG S M U N

c) If this is/was a Government cost type contract, please rate the contractor’s timeliness and accuracy in submitting monthly invoices with appropriate back-up documentation, monthly status reports/budget variance reports, compliance with established budgets and avoidance of significant and/or unexpected variances (under/overruns)

E VG S M U N

d) Is the contractor’s accounting system adequate for management and tracking costs? (If no, please explain below)

Yes No

e) IF this is/was a government contract, has/was this contract partially or completely terminated for default or convenience, or are there any pending terminations? (Indicate if show cause or cure notices were issued, or any default action below)

Yes No

f) Have there been any indications that the contractor has had any financial problems?

Yes No

6. SAFETY/SECURITY

a) Contractor’s ability to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues (Includes: following the users

E VG S M U N

rules, regulations, and requirements regarding housekeeping, safety, correction of noted deficiencies, etc)

b) Contractor compliance with all security requirements for the project and personnel security requirements

E VG S M U N

7. GENERAL

a) Ability to successfully respond to emergency and/or surge situations (including notifying COR, PM or Contracting Officer in a timely manner regarding urgent contractual issues)

E VG S M U N

b) Compliance with contractual terms/clauses (If M/U, please specify below)

E VG S M U N

c) Would you hire or work with this firm again?

Yes No

d) Overall rating for work performed by this contractor.

E VG S M U N

Please provide responses to the questions above (if applicable) and/or additional remarks.

Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (please attach additional pages if necessary):