Attachment__5_Past_Performance_Questionnaire-SOL-NC-15-00015.pdf

Attachment #5

Past Performance Questionnaire

S O U R C E S E L E C T I O N S E N S I T I V E I N F O R M A T I O N

(TO BE COMPLETED BY OFFEROR PRIOR TO MAILING TO REFERENCE)

Name of Offeror:

Contract Number:

Contract Title:

Contract Value:

Type of Contract:

Period of Performance:

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

Performance Elements

Not

Applicable

Outstanding

Satisfactory

Unsatisfactory

1. Quality of Product or Service

2. Timeliness of

Performance

3. Effectiveness of

Management(including subcontractors)

4. Initiative in

Meeting Requirements

5. Response to

Technical Direction

6. Responsiveness to

Performance Problems

7. Compliance with Cost

Estimates

8. Customer

Satisfaction

9. Overall Performance

10. Remarks on outstanding performance:

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

11. Remarks on unsatisfactory performance:

(Provide data supporting this observation; you may continue on separate sheet if needed.)

12. Please identify any corporate affiliations with the offeror.

13. Would you do business with this firm again?

14. Information provided by:

Agency/Firm:

Name:

Title:

Mailing Address (Street and P.O. Box)

City, State and Zip Code

Telephone Number: