Attachment 0001 - Experience Reporting Form.pdf

ATTACHMENT 0001

EXPERIENCE REPORTING FORM

W912DY-19-R-0030 Initial Outfitting & Transition (IO&T)

Project Experience Tracking Number: of

a. Project Title:

b. Name of Offeror:

c. Role of Offeror (Prime, Joint Venture Partner, Key Subcontractor, Subcontractor, etc.):

d. Contract Number and Location of Project:

e. Contracting Agency/Office:

f. Contract Type and Pricing Arrangement:

g. Contract Cost (to include breakdown of costs by optional performance period):

h. Contract Dates: Began: Completed:

i. Description of Work (e.g. IO&T Services at DoD and/or VA Medical Facilities, as well as commercial medical facilities):

j. Detailed Description of Work Self-Performed as the Prime (to include what trades & specialties directly provided. If the total is inclusive of commodities, the total should be broken by total services and total commodity.):

k. Describe any Work Subcontracted to Others as the Prime (to include names, addresses, and values):

l. Reference Contact Information (to include POC name, address, phone, and email address):

m. Describe how the work referenced is relevant to the immediate acquisition. If only portions of the contract are relevant, specify which portions of the contract are relevant to the immediate acquisition:

n. Contract Performance Evaluation Rating, if known:

o. Describe past performance in terms of schedule, budget, quality control, safety, problems (if any) and corrective actions taken relative to this project:

p. Were You Ever Terminated for Convenience or for Default, Issued a Cure or Show Cause Notice, Have an Option that was Not Exercised for Performance Reasons or Assessed Liquidated

Damages? If “yes”, provide explanation:

If the Role of the Offeror is Joint Venture Partner, Key Subcontractor, Subcontractor, etc. please continue to q) through w). Do not continue if the Role of the Offeror is Prime. Refer to your answer in c).

ATTACHMENT 0001

EXPERIENCE REPORTING FORM

W912DY-19-R-0030 Initial Outfitting & Transition (IO&T)

q. Offeror’s Subcontract Amount:

r. Subcontract Percentage of Total Prime Contract as listed in g) above:

s. Description of Work (e.g. IO&T Services at DoD and/or VA Medical Facilities, as well as commercial medical facilities):

t. Detailed Description of Work Self-Performed by the Offeror (to include what trades & specialties directly provided. If the total is inclusive of commodities, the total should be broken by total services and total commodity.):

u. Describe any Work Subcontracted to Others by the Offeror (to include names, addresses, and values):

v. Reference (Client or Prime) Contact Information (includes POC name, address, phone, and email address):

w. If work supported involves multiple facilities and types, identify the percentage of total facilities square footage attributed to medical treatment facilities.