ATTACHMENT_09_-_Past_Performance_Questionnaire.docx

APPENDIX D

Performance Assessment

Performance Assessment Questionnaire – Cover Letter

Your Company's Letterhead Date:

To:

We have listed your firm as a reference for the work we have performed for you as listed below. Our firm has submitted a proposal under W912L1-19-R-0002, for the Mobile Medical and Dental project advertised by the Texas Army National Guard (TXARNG), Camp Mabry, 2200 W 35th, Austin, TX 78702-1222. In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance.

Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. Understand that while the responses to this questionnaire may be released to the offeror, in accordance with FAR 15.306 (e) (4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained. Only one response from each office is required.

Please send your completed questionnaire to the following address to arrive no later than 10 July 2019 @ 10 a.m. . Do not return them to our company.

MAIL TO:

TXARNG-Camp Mabry 2200 W 35th – Bldg. 66 ATTN: Carol J. Koenig, Contracting Officer Austin, TX 78702-1222 Or Email to: regina.m.mckinnie.civ@mail.mil

If you have questions regarding the attached questionnaire, or require assistance, please contact the Contracting Officer. E-Mail is preferred.

Thank you for your assistance.

Signature and Title

Past Performance Assessment Questionnaire

Please provide your candid responses. The information that you provide will be used in the awarding of federal contracts. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does and/or notify the Contracting Officer. Please return the completed Questionnaire to the Contracting Officer identified in the cover letter within the stated timeframe.

Rating Definitions:

Substantial Confidence: 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. The offeror has been highly successfully in performing the required effort.

Satisfactory Confidence: 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. The offeror has successfully performed the required effort.

Limited Confidence: 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. The offeror has had little success performing the required effort.

No Confidence: Performance does not meet most contractual requirements. Serious problems with contractor performance were experienced for which the corrective actions were ineffective. The offeror has not successfully performed the required effort.

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:

Total Contract Value:

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) *Note: rationale is required for each response.

A. Compliance Services, Documents, and Related Deliverables to Meet the Performance Work Statement and Regulations

· Substantial Confidence

· Satisfactory Confidence

· Limited Confidence

· No Confidence

Rationale: __________________________________________________________

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

· Limited Confidence

· No Confidence

Rationale: __________________________________________________________

C. Timeliness of Performance for Services at the Event to include Post Case Management, if applicable

· Limited Confidence

· No Confidence

Rationale: __________________________________________________________

D. Utilization of Small Business - to include adhering to the small business participation plan or the subcontracting plan, as applicable.

· Limited Confidence

· No Confidence

Rationale: __________________________________________________________

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

· Limited Confidence

· No Confidence

Rationale: __________________________________________________________

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:

Point of Contact (Name): __________________________________________

Telephone Number: ______________________________________________

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 to the Contracting Officer identified in the cover letter.

Thank you for your assistance.