Optional Form Past Performance Questionnaire

Attachment J99 Optional Past Performance Questionnaire (PPQ) Form PPQ-0

Volume I – Factor 2 – Past Performance

FOR OFFICIAL USE ONLY, SOURCE SELECTION INFORMATION (FAR 3.104)

Response to Solicitation 75H70126R00026

(Cover page not required in submission)

Attachment J99 Solicitation 75H70126R00026
Company Experience Form (Past Performance)

PAST PERFORMANCE QUESTIONNAIRE (Form PPQ-0)

CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information

Firm Name: CAGE Code:
Address:SAM UEI:
Phone Number:
Email Address:
Point of Contact: Contact Phone Number:
2. Work Performed as: FORMCHECKBOX Prime Contractor FORMCHECKBOX Sub Contractor FORMCHECKBOX Joint Venture FORMCHECKBOX Other (Explain) Percent of project work performed:
If subcontractor, who was the prime (Name/Phone #):

3. Contract Information

Contract Number:
Delivery/Task Order Number (if applicable):
Contract Type: FORMCHECKBOX Firm Fixed Price FORMCHECKBOX Cost Reimbursement FORMCHECKBOX Other (Please specify): Contract Title:
Contract Location:
Award Date (mm/dd/yy):
Contract Completion Date (mm/dd/yy):
Actual Completion Date (mm/dd/yy):
Explain Differences:
Original Contract Price (Award Amount):
Final Contract Price (to include all modifications, if applicable): Explain Differences:

4. Project Description:

Complexity of Work FORMCHECKBOX High FORMCHECKBOX Med FORMCHECKBOX Routine How is this project relevant to project of submission? (Please provide details such as similar equipment, requirements, conditions, etc.)

CLIENT INFORMATION (Client to complete Blocks 5-8)

5. Client Information

Name:
Title:
Phone Number:
Email Address:
6. Describe the client’s role in the project:

7. Date Questionnaire was completed (mm/dd/yy):

8. Client’s Signature:

NOTE: IHS DES REQUESTS THAT THE CLIENT COMPLETES THIS QUESTIONNAIRE AND SUBMITS DIRECTLY BACK TO THE OFFEROR. THE OFFEROR WILL SUBMIT THE COMPLETED QUESTIONNAIRE TO IHS WITH THEIR PROPOSAL, AND MAY DUPLICATE THIS QUESTIONNAIRE FOR FUTURE SUBMISSION ON IHS SOLICITATIONS. CLIENTS ARE HIGHLY ENCOURAGED TO SUBMIT QUESTIONNAIRES DIRECTLY TO THE OFFEROR. HOWEVER, QUESTIONNAIRES MAY BE SUBMITTED DIRECTLY TO IHS. PLEASE CONTACT THE OFFEROR FOR IHS POC INFORMATION. THE GOVERNMENT RESERVES THE RIGHT TO VERIFY ANY AND ALL INFORMATION ON THIS FORM.

ADJECTIVE RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT

YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE

-1416051206500

RATINGDEFINITIONNOTE

-12954010922000
(E) Exceptional