Attachment R - Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

Note: Questionnaire submitted by some other entity other than the reference will not be accepted.

When filled in, this document is Source Selection Sensitive Information IAW FAR 3.104.

SECTION 1: CONTRACT IDENTIFICATION

Contractor
Cage Code
Contract Number
Contract Type
Was this a competitive contract? Yes No
Period of performance
Initial contract cost $
Current/final contract cost $
Reasons for differences between initial contract cost and final contract costs 914704187377914704452553914704717983914704983159

Description of service provided
9147042625239147045276999147047928759147041058051

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION

Customer or agency name
Customer or agency description
914704262045914704527221914704791877

Geographic description of services under this contract, i.e., local, nationwide, worldwide, other commands 9147042482419147045134179147047785939147041043769

SECTION 3: EVALUATOR IDENTIFICATION

Name
Title
Phone/Fax
914704186114
Number of years evaluator worked on subject contract
914704186324

SECTION 4: EVALUATION

Please indicate your satisfaction with the contractor’s performance by placing an X in the appropriate block using the scale provided to the right of each question. This scale is defined as follows:

Code
Performance Level
S
Satisfactory – The contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the contractor appear or were satisfactory. M
Marginal – Performance does not meet some contractual requirements. The contractual performance 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.
US
Unsatisfactory – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.
NA
Not Applicable – Unable to provide a score.

Small and Small Disadvantaged Business Participation
S
M
US
NA
S1. Ability to meet or exceed small business and small disadvantaged business goals set forth in the approved subcontracting plan.

S2. Ability to effectively manage small business participation to meet technical performance.

Technical Performance
S
M