PAST PERFORMANCE QUESTIONNAIRE



EXHIBIT EREFERENCES QUESTIONNAIRESacramento Employment and Training AgencyName of organization for which the questionnaire is being completed: FORMTEXT ?????Name of company completing the questionnaire: FORMTEXT ?????Information provided by:Name of individual: FORMTEXT ?????Title: FORMTEXT ?????Signature:Date: FORMTEXT ?????Mailing Address: FORMTEXT ?????City, State, Zip Code: FORMTEXT ?????Telephone: FORMTEXT ????? Fax: FORMTEXT ?????E-mail address: FORMTEXT ?????Contract Information:Contract Title: FORMTEXT ?????Contract Amount: FORMTEXT ?????Period of Performance: FORMTEXT ?????Description of Services Provided: FORMTEXT ?????EXHIBIT EPlease refer to the following descriptions when providing rating of each performance element.PERFORMANCE LEVELDescriptionEXCELLENTThe contractor’s performance clearly exceeds contractual requirements.SATISFACTORYNo problems exist or only minor problems for which solutions are in hand.MARGINALProblems exits for which the identified solution may not be adequate, but the problem appears to be within the contractor’s ability to solve.UNSATISFACTORYSerious problems exist which may be outside the contractor’s ability to solve. The contractor is in danger of not being able to satisfy contractual requirements and timely recovery is not likely.NEUTRAL/NOTAPPLICABLE (N/A)Not applicable or unable to provide information.The evaluator identified above supplies the rating below,NOT the Proposer organization.Please check the appropriate box for each performance element, and provide narrative information on the following pages.Performance Elements N/AExcellentSatisfactoryMarginal UnsatisfactoryQuality of Product or Service FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Effectiveness of Management (including subcontractors) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Initiative in Meeting Requirements FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Responsiveness to Technical Direction or Technical Assistance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Responsiveness to Performance Problems FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Customer Satisfaction FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Overall Performance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EXHIBIT EPlease provide narrative remarks and data, as appropriate, for each of the performance elements, particularly for ratings of Excellent or Unsatisfactory. You may continue on a separate sheet if needed.1.Quality of Product or Service FORMTEXT ?????2. Effectiveness of Management (including subcontractors) FORMTEXT ?????3. Responsiveness to Technical Direction or Technical Assistance FORMTEXT ?????4. Responsiveness to Performance Problems FORMTEXT ?????5. Overall Performance FORMTEXT ?????6. General Remarks on Excellent Performance: FORMTEXT ?????7. General Remarks on Unsatisfactory Performance: FORMTEXT ?????Would you do business with this organization (the proposer) again? FORMTEXT ?????Yes FORMTEXT ?????NoEXHIBIT FSACRAMENTO WORKS JOB CENTER SYSTEM SERVICESPARTNER ROLES, RESPONSIBILITIES AND RESOURCES CHARTABCDEOrganization TypeName of PartnerRole and ResponsibilitiesLeveraged FundsDescription of Fund SourceProposer Name FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????Local Employers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????One-Stop Partners FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????????????? FORMTEXT ????????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Others FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total Leveraged Funds$ FORMTEXT ?????EXHIBIT GCURRENT FUNDING SOURCES FORMProposer Agency: FORMTEXT ????? ????? Funding SourceGrant PeriodAmount Area 4 Agency on Aging FORMTEXT ????? FORMTEXT ?????City Contribution (General Fund) FORMTEXT ????? FORMTEXT ?????Comm. Development Block Grant FORMTEXT ????? FORMTEXT ?????CSBG – SETA FORMTEXT ????? FORMTEXT ?????CSBG – Other FORMTEXT ????? FORMTEXT ?????County Alcoholism FORMTEXT ????? FORMTEXT ?????County Substance Abuse FORMTEXT ????? FORMTEXT ?????County Mental Health FORMTEXT ????? FORMTEXT ?????FEMA FORMTEXT ????? FORMTEXT ?????Fed. – DOL FORMTEXT ????? FORMTEXT ?????Fed. – HHS FORMTEXT ????? FORMTEXT ?????CalWORKs – County DHA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Office of Criminal Justice FORMTEXT ????? FORMTEXT ?????RSS FORMTEXT ????? FORMTEXT ?????WIOA Adult FORMTEXT ????? FORMTEXT ?????WIOA Dislocated Worker FORMTEXT ????? FORMTEXT ?????WIOA Youth FORMTEXT ????? FORMTEXT ?????WIOA Discretionary FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Head Start FORMTEXT ????? FORMTEXT ?????State Dept. of Health Services FORMTEXT ????? FORMTEXT ?????State CSD FORMTEXT ????? FORMTEXT ?????United Way FORMTEXT ????? FORMTEXT ?????Federal (Other) FORMTEXT ????? FORMTEXT ?????State (Other) FORMTEXT ????? FORMTEXT ?????Tuition/Fees FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????EXHIBIT HPENDING APPLICATIONS FORMProposer Agency: FORMTEXT ????? PROGRAM OR PROJECT TITLE AND PURPOSE(Brief Summary)FUNDING SOURCEAMOUNT FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specify funding source by name. The following list is provided for reference; however, it is not exhaustive and other sources not named should be identified.Area 4 Agency on AgingCity Contribution (General Fund)Head StartComm. Development Block GrantState Dept. of HealthCSBG - SETAState DEOCSBG - OtherFEMACounty AlcoholismUnited WayCounty Substance AbuseWIOA, YouthCounty Mental HealthWIOA, AdultFederal (Other)WIOA, Dislocated WorkerFederal – Dept. of LaborState (Other)Federal – Health & Human ServicesTuition/FeesCalWORKsOtherOffice of Criminal JusticeRSS ................
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