Form 3700/57 Past Performance Questionnaire

OMB No.: 3064-0072

Expiration Date: 03/31/2019

Federal Deposit Insurance Corporation

PAST PERFORMANCE QUESTIONNAIRE

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paperwork Reduction Act Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OBM control number.

TO: Government agency or commercial organization (i.e., customer) with knowledge on offeror's past performance.

1. Please complete this questionnaire, which concerns the past performance of a contractor or subcontractor who is doing business (or has done business) with you, and is interested in doing business with the Federal Deposit Insurance Corporation (FDIC). Handwritten responses are sufficient. If you need more space than that provided, please attach additional pages. Responses will be treated as source selection sensitive information. The contractor who provided FDIC with your name as a reference was informed, via a solicitation provision, that by listing you as a reference and requesting your submission of the questionnaire, they are authorizing you to release information to FDIC relative to their past performance, whether it is positive or negative information.

Fax or email the completed questionnaire to the attention of the responsible FDIC Contracting Officer. The offeror must either fill in below the solicitation number, fax number, email address, and name of Contracting Officer prior to providing you with the questionnaire, or provide you with the information to fill in. Your completed questionnaire must be provided directly to the FDIC Contracting Officer from you. FDIC will not accept completed questionnaires sent from the offeror.

FDIC Solicitation Number:		     
*ATTN: Contracting Officer:		     
*Fax:	(     )      
*Email:	     		@FDIC.gov
*Offeror must obtain this Information from paragraph (e) of FDIC solicitation provision 7.3.2-16

2. Please complete the following identifying information and past performance assessment:
A. Contractor:	     
B. Contract Number:		     
C. Period of Performance:			     
D. Total Contract Amount (Including any Options)					     
E. Describe product acquired:				     
     

3. Explanation of codes:
CODE	PERFORMANCE LEVEL
E	EXCEPTIONAL -	Performance meets contractual requirements and exceeds many (requirements). The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.
V	VERY GOOD -	Performance meets contractual requirements and exceeds some (requirements). The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.
S	SATISFACTORY -	Performance meets contractual requirements. The contractual performance of the element being assessed contains 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 of the element being assessed 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.
U	UNSATISFCTORY -	Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element being assessed contains serious problem(s) for which the contractor's corrective actions appear or were ineffective.
N	NOT APPLICABLE -	Unable to provide a score. Performance in this area not applicable to effort assessed.
4. Using the codes above, place an “x” next to the appropriate letter for each item on the questionnaire and provide supporting narrative.

(1) ASSESSMENT ELEMENTS

Cost/Price Control - Rate the contractor's ability to control cost and deliver at the agreed-to price. Describe the reasons for changes to contract value (e.g., scope changes, overrun/underrun, Government-imposed schedule changes, etc.).

E V S M U N

     

(2) Schedule Adherence - How well did the contractor adhere to the agreed-to schedule? What were the causes of any schedule variances? Were data deliverables and reports submitted on time?

E V S M U N

     

(3) Performance - Rate the contractor's ability to successfully comply with the contract requirements, statement of work, subcontracting plan, etc.

E V S M U N

     

(4) Quality - How well did the contractor adhere to the requirements of a Quality Assurance Plan or Performance Based Contracting requirements? Did the services provided meet the required level of quality or results?

E V S M U N

     

(5) Business Relations - Did the contractor exhibit reasonable/cooperative behavior in dealing with problems? Was turnover of personnel frequent? Rate the contractor's responsiveness to managing changes in providing replacement personnel.

E V S M U N

     

(6) What is your overall rating of the contractor’s performance?

E V S M U N

     

(7) Identify the contractor's strengths.

     

(8) Identify the contractor's weaknesses.

     

(9) Given the choice, would you award to this contractor again? Why?

     

(10) Are you aware of any other efforts performed by this contractor similar in nature to this contract? Please identify contract/program and point of contact.

     

5. Please provide the name title Government agency or commercial organization phone number and email address of the person completing this questionnaire.

Name of Respondent:				     
Title::	     
Government agency/commercial organization					     
Telephone Number:			     
Email address:		     

Thank you for your assistance.

FDIC 3700/57 (12-18)