Past__Present_Performance_Questionnaire.doc

W911YN21-Q-0021

Source Selection Sensitive When Complete See FAR 2.101 and 3.104

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name:

Telephone Number:

Address:

Fax Number:

Point of Contact:

Project Title and Brief Description of Work:

Contract Number:

Dollar Amount:

Contract Period or Dates of Performance:

Contractor performed as the ( Prime Contractor ( Sub-Contractor ( Key Personnel.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

B. RESPONDENT INFORMATION:

Name of Respondent:

Title:

Address:

Telephone Number:

Fax Number:

Email Address:

C. MAIL, EMAIL, OR FAX COMPLETED SURVEY FORM TO:

USPFO-FL

Attn: RUTHA LAWRENCE

Email: rutha.t.lawrence.civ@mail.mil D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, G, S, M, U, and N) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

Note: Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

Performance meets contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than some minor problems for which corrective actions taken by the contractor were effective.

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor were satisfactory.

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Performance was not observed or not applicable to the current effort being reported against.

Place an “X” in the appropriate column using the definitions matrix above.

CONTRACTOR’S NAME: _______________ CONTRACT NUMBER: _______________

Remarks:

Source Selection Sensitive When Complete

See FAR 2.101 and 3.104