Att_5.docx

ATTACHMENT 5

PAST PERFORMANCE QUESTIONNAIRE

STANDARD CONTRACTOR

PAST PERFORMANCE QUESTIONNAIRE

SOL-DC-11-00006

This is a past performance questionnaire for The U.S. Environmental Protection Agency (EPA) to obtain past performance information on the contractor listed below. You should have received this questionnaire along with a Client Authorization Letter from the contractor listed below asking for your cooperation in completing this questionnaire. Information obtained in this questionnaire is for the sole purpose of evaluating the contractor’s past performance history to assist EPA in determining the best value for award of a contract resulting from our solicitation.

As a reviewer, your participation in this questionnaire is greatly appreciated.

INSTRUCTIONS:

To complete this questionnaire, the contractor should:

1. Complete the CONTRACT DATA on the next page of this questionnaire.

2. Forward this questionnaire along with a Client Authorization Letter to the reviewer.

To complete this questionnaire, the reviewer should:

1. Review the CONTRACT DATA on the next page of this questionnaire.

2. Complete the RATINGS section on the next page of this questionnaire by evaluating and assigning a rating for quality, cost control, timeliness of performance, business relations, and customer satisfaction. Include a narrative for each rating if appropriate

3. Review and complete the ADMINISTRATIVE INFORMATION table on the next page of this questionnaire.

4. Return the questionnaire to the U.S. EPA by email to dolan.sheila@epa.gov by May 20, 2016.

QUESTIONS:

If you have any questions about completing or submitting this questionnaire, please contact the Contracting Officer for this acquisition, Sheila Dolan at dolan.sheila@epa.gov.

CONTRACT DATA:

Contract Number:

Contractor Name:

Contract Title:

Contractor Address:

Contract Value:

Contractor DUNS:

Contract Type:

Contract Award Date:

Agency/Org. Name:

Reporting Period (Start):

Contracting Office:

Reporting Period (End):

Task Order Number:

Task Order Value:

Task Order Title:

Task Order Award Date:

Reporting Period (Start):

Task Order Type:

Reporting Period (End):

The remainder of this form is to be completed by the reference and returned to EPA as instructed in the Client Authorization Letter.

RATINGS:

Please check the appropriate Rating for each Performance Element.

Performance Element

1. Quality of Product or Service

2. Effectiveness of Cost Control

3. Timeliness of Performance

4. Business Relations

1. Remarks on Excellent performance:

(Provide data supporting this observation. You may continue on a separate sheet if needed.)

2. Remarks on Unsatisfactory performance:

(Provide data supporting this observation. You may continue on a separate sheet if needed.)

3. Identify any corporate affiliations with the offeror.

4. Would you do business with this firm again?

ADMINISTRATIVE INFORMATION:

5. Information provided by:

Agency/Firm:

Name: Phone:

Title:

Mailing Address: Fax:

E-mail: