Attachment_G_-_Past_Performance_Questionnaire.docx

Warehouse Support Service - Hagerstown

SAQMMA13R0003

PAST PERFORMANCE QUESTIONNAIRE

Your assistance is requested in support of a source selection.

Please complete this Questionnaire and email to:

Department of State – Office of Acquisition Management Celenne Cook @ cookcg@state.gov

Desired Response Date: 12/15/2012

When complete, the information on this form is SOURCE SELECTION SENSITIVE INFORMATION (41 U.S.C. 423) and shall be protected accordingly.

TO BE COMPLETED BY OFFEROR

1. CONTRACTOR NAME & ADDRESS:

2. CONTRACT NO.:

xxxxxx

ABC Co.

3. CONTRACT INITIATION DATE:

3817 Pleasantdale Rd

Atlanta, GA 30340

4. COMPLETION DATE:

5. CONTRACT VALUE (with options): $

6. TYPE OF CONTRACT:

7. DESCRIPTION OF CONTRACT REQUIREMENTS: xxxxxx

Please add a continuation page if additional space necessary.

TO BE COMPLETED BY EVALUATING ORGANIZATION REPRESENTATIVE

8. EVALUATION: a. EVALUATOR'S NAME, POSITION (Project Manager/ COR/ Other) AND ORGANIZATION: Director , ABC Co.

b. EVALUATOR'S PHONE NUMBER: c. MONTHS PERFORMANCE MONITORED BY EVALUATOR:

Please circle the response code for each topic (A – G) that best reflects your experience with this contractor.

O = Outstanding E = Excellent A = Adequate M = Marginal P = Poor N/O = Not Observed

A. Quality of Products and Services - Assess the contractor’s conformance to contract requirements, specifications, and standards of good workmanship (e.g., technical, professional, environmental, or safety and health standards).

O E A M P N/O

B. Performance – Assess the contractor’s performance as the General Contractor or Architect/Engineer (as appropriate) for the project.

O E A M P N/O

C. Schedule – Assess the timeliness of contractor against the schedule of activities.

O E A M P N/O

D. Technical Requirements – Assess the contractor’s ability to fulfill the technical requirements of the contract.

O E A M P N/O

E. Cost Control – Assess the contractor’s ability to manage the contract budget and control costs.

O E A M P N/O

F. Customer Satisfaction – Assess the contractor’s responsiveness to customer concerns and “user friendliness”.

O E A M P N/O

G. Overall Assessment.

O E A M P N/O

If an Award Fee contract, what was the average Award Fee % earned?

Attachment G