Past Performance Questionnaire Blank

PAST PERFORMANCE QUESTIONNAIRE

Solicitation Number:
Project Title:
CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information

Firm Name:CAGE Code:
Address:DUNs Number:
Phone Number:Email Address:
Point of Contact:Contact Phone Number:
195072096983349752969845659039698565708896982. Work Performed as:Prime ContractorSub ContractorJoint VentureOther Percent of project work performed: If subcontractor, who was the prime (Name/Phone #):

3. Contract Information

116128822877323286722287733880103228773Contract Number:Delivery/Task Order Number (if applicable): Contract Type:Firm Fixed PriceCost ReimbursementOther (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:

119786337032185318337032242011137032Complexity of WorkHighMedRoutine 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:

Section D: Performance Information: Choose the letter on the scale that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY UNSATISFACTORY OR MARGINAL RATINGS.

E
VG
S
M
U
N
Exceptional
(Outstanding)
Very Good
(Above Average)
Satisfactory
Marginal
Unsatisfactory
Not Available
Performance meets
Performance meets
Performance meets
Performance does
Performance does
No record of past
contractual
contractual
contractual
not meet some
not meet most
performance or the
requirements and
requirements and
requirements. The
contractual
contractual
record is
exceeds many to
exceeds some to
contractual
requirements. The
requirements and
inconclusive.
the Government’s
the Government’s
performance of the
contractual
recovery is not

benefit. The
benefit. The
element or sub- performance of the
likely in a timely

contractual
contractual
element contains
element or sub- manner. The