Exhibit_A_-_Past_Performance_Evaluation_Questionnaire_Form.doc

FOR OFFICIAL USE ONLY

SOURCE SELECTION INFORMATION

EXHIBIT A: PAST PERFORMANCE QUESTIONNAIRE

INSTRUCTIONS

U.S. ARMY MEDICAL RESEARCH ACQUISITION ACTIVITY

Fort Detrick, MD

The information obtained from this questionnaire will be utilized to evaluate the past and present performance of offerors submitting proposals in response to the Technology Transfer (T2) and Intellectual Property (IP) Database solicitation W81XWH-18-Q-0055. The information you provide will be instrumental in allowing the Government to evaluate how well the contractor performed under your contract(s).

a.

Please complete all sections of the attached questionnaire. Include your name and title, organizational address, e-mail address, telephone and fax number.

b.

Include the contractor’s name and address, the title and/or description of the type of work performed, the award number, the value of the contract (including options), the award and completion date of the project and the type of award/solicitation.

c.

Use the rating scale found on the bottom left corner of the questionnaire to rate each performance element.

d.

Comments are encouraged and would be appreciated. The last page may be used if additional space is needed for comments. Clear handwritten responses are sufficient.

e.

Please FAX or e-mail your response to Lisa Zarick, Contract Specialist, at 301-619-1529 or lisa.m.zarick.civ@mail.mil no later than close of business on 23 March 2018. Do not send back to the requesting company or individual. If you have any questions, please contact Lisa Zarick at 301-619-2336 or the email address listed above.

Thank you for your time and participation.

Lisa Zarick

Contract Specialist

U.S. Army Medical Research Acquisition Activity

820 Chandler Street

Ft. Detrick, MD 21702

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

Contractor:

Contract No.:

Subcontract No. (if applicable):__________________________________

POC:

Title:

(Name)

(E.G. PCO/ACO/TM)

(Agency, Telephone No., E-mail Address & Fax Number)

The following questions pertain to the contractor’s record of past (within the past three years) and current performance. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that our information be as factual and accurate as possible. Please provide examples and/or explanations (use additional pages if necessary). The following adjectival ratings shall be used in your response.

Outstanding: Performance meets contractual requirements and exceeds many requirements that benefit the end user. Work was accomplished with few, if any, minor problems for which corrective actions taken by the contractor were highly effective.

Good: Performance meets contractual requirements and exceeds some requirements that benefit the end user. Work was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Acceptable: Performance meets contractual requirements. Work was accomplished with some minor problems for which corrective actions taken by the contractor were satisfactory.

Marginal: Performance does not meet some contractual requirements. Serious problems with contractor performance were experienced for which the contractor has either not yet identified corrective actions or the corrective actions taken appear only marginally effective.

Unacceptable: Performance does not meet most contractual requirements. Serious problems with contractor performance were experienced for which the corrective actions were ineffective.

PART I. (To be completed by the Offeror)

A. CONTRACT IDENTIFICATION

Contractor/Company Name/Division:

Address:

Program Identification/Title:

Contract Number:

Contract Type:

Prime Contractor Name (if different from the contractor name cited above):

Contract Award Date:

Forecasted or Actual Contract Completion Date:

Nature of the Contractual Effort or Items Purchased:

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE

Name:

Title:

Date:

Telephone Number:

Address:

E-mail Address:

PART II. EVALUATION (To be completed by Point of Contact – Respondent)

A. Compliance of Products, Services, Documents, and Related Deliverables to Specification Requirements and Standards of Good Workmanship

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Outstanding (Explanation must be provided in Comments field below)

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Good

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Acceptable

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Marginal (Explanation must be provided in Comments field below)

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Unsatisfactory (Explanation must be provided in Comments field below) Comments:

B. Effectiveness of Project Management (to include use and control of subcontractors).

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Outstanding (Explanation must be provided in Comments field below)

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Good

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Acceptable

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Marginal (Explanation must be provided in Comments field below)

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Unsatisfactory (Explanation must be provided in Comments field below) Comments:

C. Timeliness of Performance for Services and Product Deliverables.

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Outstanding (Explanation must be provided in Comments field below)

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Good

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Acceptable

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Marginal (Explanation must be provided in Comments field below)

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D. Commitment to Customer Satisfaction and Business-like Concern for its Customers’ Interest

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Outstanding (Explanation must be provided in Comments field below)

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Good

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Acceptable

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Marginal (Explanation must be provided in Comments field below)

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E. General Comments. Provide any other relevant performance information.

F. Other Information Sources. Please provide the following information:

Are you aware of other relevant past efforts by this company?

If yes, please provide the name and telephone number of a point of contact:

G. Respondent Identification. Please provide the following information:

Organization:

Name:

Title:

Date:

Telephone Number:

Address:

E-mail Address:

PART III. RETURN INFORMATION

Please return this completed Questionnaire via e-mail to the Contracting Officer identified in the cover letter.

Thank you for your assistance.

Signature

Date

Typed or Printed Name