Attachment_11_Relevant_Experience_Questionnaire.docx

Relevant Experience Questionnaire - DiPSS

SAQMMA16R0106 – Diplomatic Platform Support Services (DiPSS) Attachment 11 –Relevant Experience Questionnaire

PURPOSE

The information used to evaluate firms is from this form and other sources, including performance evaluations, any additional data requested by the agency, and interviews with the most highly qualified firms and their references.

GENERAL INSTRUCTIONS

Part I presents the relevant experience for the DiPSS contract.

Part II presents the relevant experience of a firm or a specific branch office of a firm.

1. Prepare a separate Part II for each firm that will be part of the team proposed for a specific contract and submitted with Part I. If a firm has branch offices, submit a separate Part II for each branch office that has a key role on the team.

DEFINITIONS

Branch Office: A geographically distinct place of business or subsidiary office of a firm that has a key role on the team.

Discipline: Primary technical capabilities of key personnel, as evidenced by academic degree, professional registration, certification, and/or extensive experience.

Firm: Defined in FAR 36.102.

Key Personnel: Individuals who will have major contract responsibilities and/or provide unusual or unique expertise.

Part I - Contract-Specific Qualifications Section A. Contract Information.

1. Title and Location. Enter the title and location of the contract for which this form is being submitted, exactly as shown in the public announcement or agency request.

2. Public Notice Date. Enter the posted date of the agency's notice on the Federal Business Opportunity website (FedBizOpps), other form of public announcement or agency request for this contract.

3. Solicitation or Project Number. Enter the agency's solicitation number and/or project number, if applicable, exactly as shown in the public announcement or agency request for this contract.

Section B. Architect-Engineer Point of Contact.

4-8. Name, Title, Name of Firm, Telephone Number, Fax (Facsimile) Number and E-mail (Electronic Mail) Address. Provide information for a representative of the prime contractor or joint venture that the agency can contact for additional information.

As an attachment after Section C, present an organizational chart of the proposed team showing the names and roles of all key personnel listed in Section E and the firm they are associated with as listed in Section C.

Section E. Resumes of Key Personnel Proposed for This Contract.

Complete this section for each key person who will participate in this contract. Group by firm, with personnel of the prime contractor or joint venture partner firms first. The following blocks must be completed for each resume:

12. Name. Self-explanatory.

13. Role in This Contract. Self-explanatory.

14. Years Experience. Total years of relevant experience (block 14a), and years of relevant experience with current firm, but not necessarily the same branch office (block 14b).

15. Firm Name and Location. Name, city and state of the firm where the person currently works, which must correspond with one of the firms (or branch office of a firm, if appropriate) listed in Section C.

16. Education. Provide information on the highest relevant academic degree(s) received. Indicate the area(s) of specialization for each degree.

17. Current Professional Registration. Provide information on current relevant professional registration(s) in a State or possession of the United States, Puerto Rico, or the District of Columbia according to FAR Part 36.

18. Other Professional Qualifications. Provide information on any other professional qualifications relating to this contract, such as education, professional registration, publications, organizational memberships, certifications, training, awards, and foreign language capabilities.

Select projects where multiple team members worked together, if possible, that demonstrate the team's capability to perform work similar to that required for this contract. Complete one Section F for each project. Present ten projects, unless otherwise specified by the agency. Complete the following blocks for each project:

20. Example Project Key Number. Start with "1" for the first project and number consecutively.

21. Title and Location. Title and location of project or contract. For an indefinite delivery contract, the location is the geographic scope of the contract.

22. Year Completed. Enter the year completed of the professional services (such as planning, engineering study, design, or surveying), and/or the year completed of construction, if applicable. If any of the professional services or the construction projects are not complete, leave Year Completed blank and indicate the status in Brief Description of Project and Relevance to This Contract (block 24).

SPECIFIC INSTRUCTIONS

This matrix is intended to graphically depict which key personnel identified in Section E worked on the example projects listed in Section F. Complete the following blocks (see example below).

26. and 27. Names of Key Personnel and Role in This Contract. List the names of the key personnel and their proposed roles in this contract in the same order as they appear in Section E.

28. Example Projects Listed in Section F. In the column under each project key number (see block 29) and for each key person, place an "X" under the project key number for participation in the same or similar role.

29. Example Projects Key. List the key numbers and titles of the example projects in the same order as they appear in Section F.

Section H. Additional Information.

30. Use this section to provide additional information specifically requested by the agency or to address selection criteria that are not covered by the information provided in Sections A-G.

Section I. Authorized Representative.

31. and 32. Signature of Authorized Representative and Date. An authorized representative of a joint venture or the prime contractor must sign and date the completed form. Signing attests that the information provided is current and factual, and that all firms on the proposed team agree to work on the project. Joint ventures selected for negotiations must make available a statement of participation by a principal of each member of the joint venture.

33. Name and Title. Self-explanatory.

SAMPLE ENTRIES FOR SECTION G (MATRIX)

X

X

29. EXAMPLE PROJECTS KEY

Part II - General Qualifications See the "General Instructions" on page 1 for firms with branch offices. Prepare Part II for the specific branch office seeking work if the firm has branch offices.

a. Type. Enter the type of ownership or legal structure of the firm (sole proprietor, partnership, corporation, joint venture, etc.).

b. Small Business Status. Refer to the North American Industry Classification System (NAICS) code in the public announcement, and indicate if the firm is a small business according to the current size standard for that NAICS code (for example, Engineering Services (part of NAICS 541330), Architectural Services (NAICS 541310), Surveying and Mapping Services (NAICS 541370)). The small business categories and the internet website for the NAICS codes appear in FAR Part 19. Contact the requesting agency for any questions. Contact your local U.S. Small Business Administration office for any questions regarding Business Status.

9. Employees by Discipline. Use the relevant disciplines and associated function codes shown at the end of these instructions and list in the same numerical order. After the listed disciplines, write in any additional disciplines and leave the function code blank. List no more than 20 disciplines. Group remaining employees under "Other Employees" in column b. Each person can be counted only once according to his/her primary function. If Part II is prepared for a firm (including all branch offices), enter the number of employees by disciplines in column c(1). If Part II is prepared for a branch office, enter the number of employees by discipline in column c(2) and for the firm in column c(1).

10. Profile of Firm's Experience and Annual Average Revenue for Last 5 Years. Complete this block for the firm or branch office for which this Part II is prepared. Enter the experience categories which most accurately reflect the firm's technical capabilities and project experience. Use the relevant experience categories and associated profile codes shown at the end of these instructions, and list in the same numerical order. After the listed experience categories, write in any unlisted relevant project experience categories and leave the profile codes blank. For each type of experience, enter the appropriate revenue index number to reflect the professional services revenues received annually (averaged over the last 5 years) by the firm or branch office for performing that type of work. A particular project may be identified with one experience category or it may be broken into components, as best reflects the capabilities and types of work performed by the firm. However, do not double count the revenues received on a particular project.

11. Annual Average Professional Services Revenues of Firm for Last 3 Years. Complete this block for the firm or branch office for which this Part II is prepared. Enter the appropriate revenue index numbers to reflect the professional services revenues received annually (averaged over the last 3 years) by the firm or branch office. Indicate Federal work (performed directly for the Federal Government, either as the prime contractor or subcontractor), non-Federal work (all other domestic and foreign work, including Federally-assisted projects), and the total. If the firm has been in existence for less than 3 years, see the definition for "Annual Receipts" under FAR 19.101.

12. Authorized Representative. An authorized representative of the firm or branch office must sign and date the completed form. Signing attests that the information provided is current and factual. Provide the name and title of the authorized representative who signed the form.

FUNCTIONAL CODES FOR EMPLOYEE DISCIPLINE[footnoteRef:1] [1: SOURCES – M/PRI Staffing Chart for Post Use; A/L – ILMS Knowledge Center – Overseas Roles; ]

MANAGEMENT OFFICE

FINANCIAL MANAGEMENT

Project Manager

Accountant

Contract Manager

Cashier

Task Order Manager

Voucher Examiner

Task Order Site Manager

Management Officer

HUMAN RESOURCES

GSO OPERATIONS

FACILITIES MANAGEMENT

GSO OFFICE

Facilities Manager

General Services Officer

Gardeners

Janitors

Cafeteria Staff

PROCUREMENT

Bank Tellers

Procurement Agent

Commissary Staff

Purchase Cardholder

WAREHOUSE & SUPPLY

INFORMATION RESOURCES MANAGEMENT

Warehouse Supervisor

IMO OFFICE

Inventory Control

Information Management Officer

Order Fulfillment

Picker

INFORMATION PROGRAM OFFICE

Receiver

CUSTOMS & SHIPPING

INFORMATION SERVICES CENTER

Despatch Agency Administrator

Telephone & Radio Support

Post Shipping Staff

Mail & Pouch

Traffic Manager

Courier

Courier Travel System (CTS) Administrator

Mailroom Clerk

TRAVEL

PROPERTY MANAGEMENT

Travel Agents

Disposal Clerk

DS/ST CMMS-ILMS User

Expendable Stock Clerk

HOUSING

Loanable Property Clerk

Property Clerk

Receiving Clerk

MOTOR POOL

Accountable Property Officer

Dispatcher

Driver

Fuel Clerk

Maintenance Clerk

Motor Pool Supervisor

List of Experience Categories (Profile Codes)

Includes: All Actions Necessary to Restore, Rehabilitate, or Reclaim Property

Energy Audits

Includes: Resurfacing

Energy Infrastructure

Energy Management

Envelope Waterproofing (Above Ground)

Envelope Waterproofing (Below Ground)

Environmental Impact Studies,

Assessments or Statements

Emergency Services/Training Facilities

ESCO Projects

Combustion Engineering

Facilities Management

Communication – Voice data, Audio/Video

Fire Alarms

Construction Testing & Inspection

Facilities; Parking Decks

Development, Analysis, and Data Collection

List of Experience Categories (Profile Codes)

G05

Mapping Location/Addressing Systems

Digitizing, Compilation, Attributing,

Materials Handling Systems; Conveyors; Sorters

G06

Metallurgy

Microclimatology; Tropical Engineering

Military Design Standards

M06

Mining & Mineralogy

H01

Missile Facilities (Silos; Fuels; Transport)

Facilities

Structures

H02

Modular Systems Design; Pre-Fabricated

H03

Hazardous, Toxic, Radioactive Waste

Remediation

Abatement

H05

Naval Architecture; Off-Shore Platforms

H06

Navigation Structures; Locks

H07

Highways; Streets; Airfield Paving Parking Lots

Nuclear Facilities; Nuclear Shielding

H10

Oceanographic Engineering

H12

Ordnance; Munitions; Special Weapons

H13

Hydrographic Surveying

I01

Industrial Buildings; Manufacturing Plants

Abatement

I02

Petroleum Exploration; Refining

I03

Petroleum and Fuel (Storage and Distribution)

I04

Photogrammetry

I05

Pipelines (Cross-Country - Liquid & Gas)

I06

Areawide and State)

J01

Planning (Site, Installation, and Project)

P07

Plumbing & Piping Design

L02

Product, Machine Equipment Design

L03

Pneumatic Structures, Air-Support Buildings

Postal Facilities

Power Generation, Transmission, Distribution

Public Safety Facilities

L05

Radar; Sonar; Radio & Radar Telescopes

L06

Radio Frequency Systems & Shieldings

Railroad; Rapid Transit

Recreation Facilities (Parks, Marinas, Etc.)

Bolded Codes are used by the Division of Engineering and Architectural Services (E&AS) for the A/E Reference File and must be used when submitting your statement of qualifications to the Division of Engineering and Architectural Services. Only E&AS codes will be accepted.

List of Experience Categories (Profile Codes)

R05

Warehouses & Depots

R07

Remote Sensing

R08

Water Resources; Hydrology; Ground Water

R09

Water Supply; Treatment and Distribution

R10

Risk Analysis

Wind Tunnels; Research/Testing Facilities

R12

Roofing

Design

S01

Safety Engineering; Accident Studies; OSHA

Studies

S02

Security Systems; Intruder & Smoke Detection

S04

Sewage Collection, Treatment and Disposal

S05

Soils & Geologic Studies; Foundations

S07

Solid Wastes; Incineration; Landfill

S08

Special Environments; Clean Rooms, Etc.

Steel Structures

S10

Surveying; Platting; Mapping; Flood Plain Studies

T01

Telephone Systems (Rural; Mobile; Intercom, Etc.)

T02

Testing & Inspection Services

T03

Traffic & Transportation Engineering

T04

Topographic Surveying and Mapping

T05

Towers (Self-Supporting & Guyed Systems)

T06

Tunnels & Subways

U01

Unexploded Ordnance Remediation

U02

Urban Renewals; Community Development

U03

Utilities (Gas and Steam)

Investigation

Bolded Codes are used by the Division of Engineering and Architectural Services (E&AS) for the A/E Reference File and must be used when submitting your statement of qualifications to the Division of Engineering and Architectural Services. Only E&AS codes will be accepted.

DOSCAP Relevant Experience

PART I - CONTRACT-SPECIFIC QUALIFICATIONS

A. CONTRACT INFORMATION

1. TITLE AND LOCATION (City and State)

2. PUBLIC NOTICE DATE

3. SOLICITATION OR PROJECT NUMBER

B. Company POINT OF CONTACT

4. NAME AND TITLE

5. NAME OF FIRM

6. TELEPHONE NUMBER

7. FAX NUMBER

8. E-MAIL ADDRESS

C. PROPOSED TEAM

(Complete this section for the prime contractor and all key subcontractors.)

PARTNER

SUBCON-TRACTOR

a

CHECK IF BRANCH OFFICE

b

CHECK IF BRANCH OFFICE

c

CHECK IF BRANCH OFFICE

d

CHECK IF BRANCH OFFICE

e

CHECK IF BRANCH OFFICE

f

CHECK IF BRANCH OFFICE

D. ORGANIZATIONAL CHART OF PROPOSED TEAM (Attached)

E. RESUMES OF KEY PERSONNEL PROPOSED FOR THIS CONTRACT

(Complete one Section E for each key person.)

15. FIRM NAME AND LOCATION (City and State)

18. OTHER PROFESSIONAL QUALIFICATIONS (Security Clearance, Certifications, Publications, Organizations, Training, Awards, etc.)

19. RELEVANT PROJECTS

a

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm b

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm c

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm d

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm e

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

F. EXAMPLE PROJECTS WHICH BEST ILLUSTRATE PROPOSED TEAM'S

QUALIFICATIONS FOR THIS CONTRACT

(Present as many projects as requested by the agency, or 10 projects, if not specified.

Complete one Section F for each project.)

20. EXAMPLE PROJECT KEY NUMBER

23. PROJECT OWNER'S INFORMATION

24. BRIEF DESCRIPTION OF PROJECT AND RELEVANCE TO THIS CONTRACT (Include scope, size, and cost)

25. FIRMS FROM SECTION C INVOLVED WITH THIS PROJECT

26. NAMES OF KEY PERSONNEL

(From Section E, Block 12)

27. ROLE IN THIS CONTRACT

(From Section E, Block 13)

28. EXAMPLE PROJECTS

(Fill in "Example Projects Key" section below before completing table. Place "X" under project key number for participation in same or similar role.)

G. KEY PERSONNEL PARTICIPATION IN EXAMPLE PROJECTS

29. EXAMPLE PROJECTS KEY

I. AUTHORIZED REPRESENTATIVE

The foregoing is a statement of facts.

33. NAME AND TITLE

H. ADDITIONAL INFORMATION

30. PROVIDE ANY ADDITIONAL INFORMATION REQUESTED BY THE AGENCY

a. TYPE

b. SMALL BUSINESS STATUS

6a. POINT OF CONTACT NAME AND TITLE

7. NAME OF FIRM (If block 2a. is a branch office)

Other Employees

Total

11. ANNUAL AVERAGE PROFESSIONAL SERVICES REVENUES OF FIRM

FOR LAST 3 YEARS

(Insert revenue index number shown at right)

PROFESSIONAL SERVICES REVENUE INDEX NUMBER

1. Less than $100,000

2. $100,00 to less than $250,000

3. $250,000 to less than $500,000

4. $500,000 to less than $1 million

5. $1 million to less than $2 million

6. $2 million to less than $5 million

7. $5 million to less than $10 million

8. $10 million to less than $25 million

9. $25 million to less than $50 million

10. $50 million or greater

a. Federal Work

b. Non-Federal Work

c. Total Work

12. AUTHORIZED REPRESENTATIVE

The foregoing is a statement of facts.

c. NAME AND TITLE

PART II - GENERAL QUALIFICATIONS (If a firm has branch offices, complete for each specific branch office seeking work.)

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