ATTACHMENT__5_Past_Performance_Questionnaire_W9124J-17-R-0006_4_Jan_2017.doc

W9124J-17-R-0006

ATTACHMENT #5

4 January 2017

INSTRUCTIONS TO THE REFERENCE FOR COMPLETING

THE PAST PERFORMANCE QUESTIONNAIRE

Handwritten completion of this questionnaire is acceptable, if legible.

Please include evaluation of Contractor's performance based solely on the performance for which the contractor was/is liable. Do not let factors beyond the control of the Contractor which have resulted in performance delays or other problems bias the evaluation of the contractor's performance. In completing the questionnaire please circle a letter corresponding to your rating, or "N/A" if you are unable to provide an evaluation for any area. Please provide clear and concise narrative explanations (both positive and negative) for your answers. This is especially important for any rating above or below “satisfactory”. If more space is needed than is provided, you may use the back of the questionnaire or attach additional sheets.

The following is a definition of the scoring system used:

Exceptional: Performance meets contractual requirements and exceeds many to the Owner’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good: Performance meets contractual requirements and exceeds some to the Owner’s benefit. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory: Performance meets contractual requirements. The contractual performance of the area being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

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

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

(To be completed and returned by the “Reference”)

I. CONTRACTOR/CONTRACT IDENTIFICATION

a) Contractor (Company/Division):

b) Contract Number/Identification:

c) Contract Title (Brief Description of Work and Location):

d) Contract Type:

e) Owner: Federal/State/Local Government or Private/Commercial

f) Period of Performance:

g) Original Dollar Amount of Contract:

h) Number of Modifications:

i) Dollar Amount at Completion (or current amount, if not complete):

II. PAST PERFORMANCE/QUALITY EVALUATION:

Quality of Product or Service - Assess the contractor’s conformance to contract requirements, specifications and standards of good workmanship (e.g., commonly accepted technical, professional, environmental, or safety and health standards):

EX FORMCHECKBOX

VG FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

UNSAT FORMCHECKBOX

N/A FORMCHECKBOX

Comments:

Schedule - Assess the timeliness of the contractor against the completion of the contract, task orders, milestones, delivery schedules, administrative requirements and overall responsiveness (e.g., efforts that contribute to or effect the schedule variance):

EX FORMCHECKBOX

VG FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

UNSAT FORMCHECKBOX

N/A FORMCHECKBOX

Comments:

Business Relationships - Assess the integration and coordination of all activity needed to execute the contract, specifically the timeliness, completeness and quality of problem identification, corrective actions plans, proposal submittals, the contractor’s history of reasonable and cooperative behavior, customer satisfaction, and the timely award and management of subcontracts. Additionally, please comment as to whether the contractor met small/small disadvantaged and women-owned business participation goals:

EX FORMCHECKBOX

VG FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

Technical Competence - Assess the knowledge of, and skill in the exercise of, practices required for successful completion of the contract (understanding of laws, regulations, and procedures):

EX FORMCHECKBOX

VG FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

Describe any significant strong points:

Describe any significant weak points:

If you had a choice, would you use this company again? Yes No

Explain:

Other contacts that may be able to furnish past performance information:

(TO BE COMPLETED AND RETURNED BY THE REFERENCE.)

***YOUR NAME WILL NOT BE RELEASED OUTSIDE OF THE GOVERNMENT***

A. Name of Evaluator:

B. Title:

C. Telephone Number:

D. Company/Organization:

E. Position held in reference to the contract (Technical Inspector, Contract Administrator, etc.):

F. Length of involvement in contract:

G. Was the contractor given the opportunity to respond to all adverse past performance information?

Yes No Not Applicable Unknown

Explain:

H. Date questionnaire completed/information provided:

I. If the information was submitted in writing, the signature of the respondent:

J. If the information was obtained telephonically, the signature(s) of the government representative(s) documenting the phone call: