SAMPLE FORMAT

							                          CONTRACTOR PERFORMANCE QUESTIONAIRRE

Date:                [Date]

To:                  [Responsible Official]

From:                [Project Director]

Subject:             Evaluation of Contractor Performance


                     1.       Title of completed project [study or service]:

                     2.       Contract number:

                     3.       Date completed or terminated:

                     4.       Final cost: [Explain any deviations from contract cost.]

                     5.       Assistance furnished contractor: [Use only to show deviations from
                              proposal or contract provisions.]

                     6.       New concepts or techniques developed by contractor:

                     7.       Evaluation of contractor performance: [Relate contractor’s proposal
                              and contract provisions. Indicate degree of agency satisfaction with
                              contractor’s performance and explain why. This portion of the
                              evaluation should be prepared with complete objectivity since it will
                              become part of a file maintained for reference in future contractor
                              selections.]

                     8.       Report location: [Indicate location within the agency where copies of
                              the final report or other documents submitted by the contractor will
                              be available for reference.]

                     9.       Results: [Indicate actions taken or to be taken on the services or study
                              and an estimate of the results, benefits, and savings achieved.]




                                              Bureau of Procurement
                          555 Walnut Street, Forum Place 6th Floor | Harrisburg, PA 17101
                               717.787.5733 | F 717.783.6241 | www.dgs.state.pa.us
Revision: 2-3-2011