Attachment_4_-_Past_Performance_Questionnaire_blank.pdf

PDF 489 KB Posted Sep 7, 2018

Attached to: GSA Certified Vault Relocation Federal contract opportunity
Solicitation number: W912L2-18-Q-6031
Issued by: Department of the Army Arizona Army National Guard

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Attachment 4 - Past Performance Questionnaire blank

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File	Type	Posted
Attachment_3_-_Reference_List.doc	DOC document	Sep 7, 2018
Attachment_1_-_PWS.pdf	PDF	Sep 7, 2018
Attachment_2_-_SCA_WD.pdf	PDF	Sep 7, 2018

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PAST PERFORMANCE EVALUATION QUESTIONNAIRE

SECTION A: Contractor Information

A. Contractor’s name and address: __ _________________________________________

B. Point of Contact: _____________________________

C. Phone Number (with area code): _________ __________

D. Contract number: ________________________________________

E. Project Title or Description of Work performed under this project: ___ _______________________________

F. Contract	Type:
	Firm‐Fixed‐Price	Indefinite‐Delivery/Indefinite	Quantity	Task	Order	Cost‐Reimbursement

G. Contract Award Date: Scheduled Completion Date: _____________________________

H. Contract Award Amount: Current/Final Project Amount: ____________________

I. Contractor	being	evaluated	performed	as	the:
	Prime	Contractor				Subcontractor	Supplier	on	this	contract/order.

SECTION B: RESPONDENT INFORMATION

EVALUATED BY:

(Signature) (Date)

_________________________________ Organization:		____________________________________
(Typed	or	Printed	Name)

______________________ Address: _______________________________ (Title)

(Email	Address)
Phone	Number:	_______________________________

NOTE: The identity of individual(s) providing the reference information shall not be disclosed.

Source Selection Sensitive

PERFORMANCE	RATING	QUESTIONNAIRE
(Contractor	to	forward	to	their	references	for	completion)

(This

Questionnaire,

when

completed,

shall

treated

Source

Selection

Sensitive

accordance

with

FAR

3.104‐3

and

shall

not

disclosed

anyone

outside

the

Government)

The

RATING

definitions

are

follows:

EXCEPTIONAL

–

Performance

met/meets

contractual

requirements

and

exceeded/exceed

many

requirements

the

organization’s

benefit.

contractual

performance

problems

for

the

element

being

assessed

have

occurred

any

minor

problems

occurred

the

corrective

actions

taken

the

contractor

were

highly

effective.

VERY

GOOD

–

Performance

met/meets

contractual

requirements

and

exceeded/exceeds

some

requirements

the

organization’s

benefit.

The

contractual

performance

the

element

being

assessed

was

accomplished

with

some

minor

problems

for

which

corrective

actions

taken

the

contractor

were

effective.

SATISFACTORY

–

Performance

met/meets

contractual

requirements.

The

contractual

performance

the

element

being

assessed

was

accomplished

with

some

minor

problems

for

which

corrective

actions

taken

the

contractor

were

satisfactory.

MARGINAL

–

Performance

did

not/does

not

meet

some

contractual

requirements.

The

contractual

performance

the

element

being

assessed

reflects

serious

problem

for

which

the

contractor

has

not

yet

identified

corrective

actions,

the

contractor’s

proposed

actions

appear

only

marginally

effective,

were

not

fully

implemented.

UNSATISFACTORY

–

Performance

did

not/does

not

meet

most

contractual

requirements

and

recovery

not

likely

timely

manner.

The

contractual

performance

the

element

being

assessed

contains

serious

problem(s)

for

which

the

contractor’s

corrective

actions

were

ineffective

were

not

implemented

timely.

N NOT APPLICABLE – Unable to provide a score. Performance in this area not applicable.

PERFORMANCE	RATING	QUESTIONNAIRE
(Contractor	to	forward	to	their	references	for	completion)

(This

Questionnaire,

when

completed,

shall

treated

Source

Selection

Sensitive

accordance

with

FAR

3.104‐3

and

shall

not

disclosed

anyone

outside

the

Government)

The contractor:

1 How efficient was the contractor in abiding by all Rules, Regulations, Laws, and Safety Standards?

2 Were you satisfied with the quality of service performed or items supplied?

3 How effective were the contractor’s quality control and/or inspection procedures?

4 How well did the contractor perform in a respect to timeliness and schedule?

5 How well did the contractor resolve Issues/

Problems/Customer Complaints?

6 How flexible, cooperative, reasonable was the contractor, particularly when faced with short‐notice mission changes or requirements changes?

7 How well was the contractor	able	to	maintain	a
good relationship with	agency	contracting	and
technical/project	management	personnel?

8 How likely are you to award another contract to this contractor?

9 Was	the	contractor	ever	issued	a	cure or show cause
notice	under	the	referenced	contract?	If	yes	explain
outcome	in	‘remarks’ section	below.

ADDITIONAL REMARKS:

**Please forward this questionnaire directly to the 162D Wing Contracting Office POC identified below**

POC:	Michael Salmon
E‐MAIL:	michael.salmon.5@us.af.mil

Text8:

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Text18:

Text19:

Text20:

Check Box25: Off

Text26:

Text27:

Text28:

Text29:

Text30:

Text31:

Text32:

Text33:

Check Box1: Off

Check Box2: Off

Check Box3: Off

Check Box4: Off

Check Box5: Off

Text7:

Dropdown1: [Marginal]

Dropdown3: [Satisfactory]

Dropdown4: [Marginal]

Dropdown5: [Satisfactory]

Dropdown6: [Satisfactory]

Dropdown7: [Marginal]

Dropdown8: [Satisfactory]

Dropdown9: [Somewhat Likely]

Dropdown10: [No]

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