[INSTRUCTIONS]{.underline}

You have been identified as a Past Performance Reference for the
contractor indicated in Block 1 below. This contractor is proposing on a
U.S. Patent and Trademark Office (USPTO) acquisition for USPTO's Pre
Grant Publication Classification Services. We value your input and
appreciate greatly your willingness to thoughtfully complete this
questionnaire.

+-----------------------------------------------------------------------+
| > Block 1. Contractor Name:                                           |
+-----------------------------------------------------------------------+

Please complete the following steps (1) Fully complete the questionnaire
and complete the signature page on page 4, (2) Place in a
**[sealed]{.underline}** envelope which contains your agency's/company's
letter head and (3) Return to the offeror you evaluated for inclusion in
offeror's proposal to be submitted to the USPTO by the closing date of
the RFP. If you have questions, please contact our Contracting Officer,
Chris Hannah, at (571)-272-6555.

Please use the supplemental information section at the end of the
questionnaire to expand on your ratings, making sure to identify your
comments with the appropriate question number. You may expand on and
more fully discuss any of the questions. Use extra pages as necessary.
Negative responses may be referred to the contractor to permit rebuttal.
Neither your name nor position within your organization will be divulged
either during or after this survey has been completed.

**Contract Information**

Contractor/Division:

Program Title:

Contract Number:

Contract Award Date:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

Contract Completion Date:

Period of Performance:

Type of Contract:

Total Dollar Amount of Contract:

**[DESCRIPTION OF MAIN ELEMENTS OF WORK PERFORMED UNDER THE
CONTRACT]{.underline}**

The following are the definitions for the rating system being used:

**5 - [Excellent ]{.underline}**-- No issues. Requirements were achieved
within cost, on time, and in conformance with contract.

**4 - [Good ]{.underline}**-- Issues did not impact achievement of
requirements.

**3 - [Average ]{.underline}**-- Issues required minor Agency resources
to ensure achievement of requirements.

**2 - [Marginal ]{.underline}**-- Issues required major Agency resources
to ensure achievement of requirements.

**1 - [Unsatisfactory]{.underline}** -- Issues compromised the
achievement of requirements.

####### QUESTIONNAIRE

**[(Please check the appropriate box for each rating
factor)]{.underline}**

####### 

+--------------------------------------------+-------+---+---+---+---+---+
| **QUALITY:**                               | N/A   | 1 | 2 | 3 | 4 | 5 |
+--------------------------------------------+-------+---+---+---+---+---+
| Compliance with contract requirements,     |       | # | # | # | # | # |
| accuracy,                                  |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| appropriateness of personnel, technical    |       | # | # | # | # | # |
| excellence                                 |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       |   |   |   |   |   |
+--------------------------------------------+-------+---+---+---+---+---+
| **CUSTOMER SERVICE:**                      | N/A   | 1 | 2 | 3 | 4 | 5 |
+--------------------------------------------+-------+---+---+---+---+---+
| Satisfaction of end users, team approach   | ###   | # | # | # | # | # |
| with customer,                             | ####  | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| positive customer feedback, courteous      |       | # | # | # | # | # |
| interactions,                              |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| prompt responses                           |       | # | # | # | # | # |
|                                            |       |   |   |   |   |   |
+--------------------------------------------+-------+---+---+---+---+---+
| **TIMELINESS OF PERFORMANCE:**             | N/A   | 1 | 2 | 3 | 4 | 5 |
+--------------------------------------------+-------+---+---+---+---+---+
| Reliable, responsive, completed on time,   | ###   | # | # | # | # | # |
| no penalties                               | ####  | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| or liquidated damages assessed             |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       |   |   |   |   |   |
+--------------------------------------------+-------+---+---+---+---+---+
| **BUSINESS RELATIONS:**                    | N/A   | 1 | 2 | 3 | 4 | 5 |
+--------------------------------------------+-------+---+---+---+---+---+
| Effective Management, businesslike         | ###   | # | # | # | # | # |
| correspondence,                            | ####  | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| flexible, prompt notification of problems, |       | # | # | # | # | # |
| proactive,                                 |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
| effective solutions                        |       | # | # | # | # | # |
|                                            |       |   |   |   |   |   |
+--------------------------------------------+-------+---+---+---+---+---+
| **OVERALL EVALUATION:**                    | N/A   | 1 | 2 | 3 | 4 | 5 |
+--------------------------------------------+-------+---+---+---+---+---+
| How would you rate the contractor's        | ###   | # | # | # | # | # |
| overall performance?                       | ####  | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       | # | # | # | # | # |
|                                            |       |   |   |   |   |   |
+--------------------------------------------+-------+---+---+---+---+---+

####### 

WOULD YOU AWARD ANOTHER CONTRACT TO THIS VENDOR/CONTRACTOR?

**YES** \_\_\_\_\_ OR **NO \_\_\_\_\_**

INDICATE REASONS FOR YOUR RESPONSE (additional comments may be attached)

**[SUPPLEMENTAL INFORMATION]{.underline}**

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**[SIGNATURE PAGE]{.underline}**

CUSTOMER ORGANIZATION

NAME AND ADDRESS

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Evaluator's Printed Name Title/Role (e.g., Program Manager, Contracting
Officer)

Evaluator's Signature Date Phone

Please note the following regarding the confidentiality of your
assessment:

By law, the Government will not disclose the names of individuals
providing reference information during discussions with the contractor
identified in Block 1 below.