Form OST F 5020.2 OST F 5020.2 Mentor Protégé PROGRAM EVALUATION Participant Report

U.S. Department of Transportation
Mentor Protégé Program Evaluation

Participant Annual Report

OMB Control Number: 2105-xxxx

Expiration Date: mm/dd/yyyy

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-XXXX. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization (OSDBU) Room W56-312, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

PART A – MENTOR INFORMATION

1. Business Name

2. Business Mailing Address (Do not include P.O Box)

3. Business Physical Address

4. Phone Number:

5. Point of Contact:

6. Email address:

PART B – PROTEGE INFORMATION

7. Protégé Name

8. Business Mailing Address (Do not include P.O. Box)

9. Business Physical Address

10. Phone Number:

11. Point of Contact

12. Email Address:

PART C: PERIOD OF PERFORMANCE

13. Agreement Period of Performance

Start Date: End Date:

PART D – INSTRUCTIONS

Please complete this form at the end of the Mentor-Protégé agreement and submit to the Director of the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization by fax at (202) 366-7228 or email at [email protected] . Please base your ratings on the criteria listed below:

5 - Exceptional	4 – Very Good	3 – Satisfactory	2 - Fair	1 - Unsatisfactory
Consistently exceeds in achieving goals and objectives far above the established standards	Generally exceeds the established performance standards	Meets the established performance standards	Meets some, but not all, of the established performance standards	Generally fails to meet the established performance standards

Proceed to PART E on page 2 to complete the evaluation.

U.S. Department of Transportation
Mentor Protégé Program Evaluation

Program Participant Evaluation

OMB Control Number: 2105-xxxx

Expiration Date: mm/dd/yyyy

PART E – EVALUATION

14. Evaluation

1. Performance Elements: 1 2 3 4 5 N/A Comments

Procurement Program Knowledge: Mentor staff knowledge of the federal procurement process met protégé’s expectations.
Developmental Work: Development assistance provided to the Protégé was adequate, as agreed upon in the Mentor-Protégé agreement.
Competences: The protégé’s staff knowledge of DOT and federal procurement process increased from the time the firm entered the Mentor-Protégé agreement.
Business Acumen: Protégé staff acquired techniques to improve contract performance increasing protégé’s ability to compete and perform on DOT and/or federal contracts.
Subcontracting programs: Protégé staff demonstrates understanding and knowledge of DOT subcontracting programs.
Mentor/Protégé selection: The process to select the mentor or the protégé is adequate.
Agency Role: DOT participation in the program is adequate.
Overall Performance: Mentor Protégé program provides the ability to enhance small business participation in DOT Procurement programs.

2. Was the developmental assistance provided to the protégé useful to enhance its core capabilities?

____________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

3. How would you improve DOT’s Mentor-Protégé program?

____________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

4. What other factors, relevant to the developmental assistance, would you like to comment upon?

____________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

5. Has the protégé been able to compete in federal procurement opportunities since the Mentor-Protégé agreement was signed?

____________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

6. Other Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Would the mentor or the protégé be willing to participate in the program again in the future? □ Yes □ No

PART F – REVIEWER’S SIGNATURE

15. Reviewer’s Signature:

Signature: ___________________________________________ Date: ___________________

Print Name: _________________________________________ Title: ________________________________________________

General Instructions

Purpose of Form

Use form Mentor Protégé Program Evaluation form, OMB Control Number 21xx-xxxx, to evaluate the performance of businesses that have entered and finished into a Mentor Protégé agreement in DOT’s Mentor-Protégé program.

How do I Obtain More Information?

You can contact the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization for further information:

Email. [email protected] .

Voice. 1-800-532-1169 or 202-366-1930. A long-distance charge to callers located outside of the local calling area will apply when calling the 202-366-1930 number.

For direct assistance, please contact the Field Office that serves your state. A complete list of field offices, the states that each region serves, and their contact information is located at http://www.osdbu.dot.gov/regional/index.cfm.

How to submit the evaluation

You can submit the Mentor Protégé program evaluation to the Director of the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Utilization by email or by fax. Use only one method per evaluation. Evaluations must be received within thirty (30) days from the Mentor-Protégé agreement end date.

Email. Scan your signed evaluation to a pdf document and email to [email protected].

Fax. Fax your signed evaluation to (202) 366-7228.

Specific Instructions

Print or type all entries on the Mentor Protégé Program evaluation, OMB Control Number 2105-xxxx. The evaluation form is an electronically fillable form. We strongly suggest evaluators utilize the electronically fillable form to complete the evaluation entries. Follow the instructions for each line to expedite processing and to avoid unnecessary requests for additional information.

Line 1. Mentor Name. Enter the business name of the mentor.

Line 2. Business Mailing Address. Enter the mailing address of the mentor’s primary physical location. Do not enter a P.O. Box here.

Line 3. Business Physical Address Enter the physical address of the mentor’s primary physical location.

Line 4. Phone Number: Enter the mentor’s primary phone number.

Line 5. Mentor Point of Contact. Enter the name of the mentor’s primary point of contact for the Mentor-Protégé program.

Line 6. Email Address. Enter the email address of the mentor’s primary point of contact.

Line 7. Protégé Name. Enter the business name of the protégé.

Line 8. Business Mailing Address. Enter the mailing address of the protégé’s primary physical location. Do not enter a P.O. Box here.

Line 9 Business Physical Address Enter the physical address of the protégé’s primary physical location.

Line 10. Phone Number: Enter the mentor’s primary phone number.

Line 11. Protégé Point of Contact. Enter the name of the mentor’s primary point of contact for the Mentor-Protégé program.

Line 12. Email Address. Enter the email address of the mentor’s primary point of contact.

Line 13. Period of Performance. Enter the period of Performance for the report.

Line 14a. Performance Elements. Rate the program performance and enter comments for each performance element. Rate each element on the following scale:

5 - Exceptional
Consistently exceeds in achieving goals and objectives far above the established standards	N/A Not applicable. Performance element does not apply to the type of developmental assistance
3 – Satisfactory	4 – Very Good
Meets the established performance standards	Generally exceeds the established performance standards
1 - Unsatisfactory	2 - Fair
Generally fails to meet the established performance standards	Meets some, but not all, of the established performance standards

Line 14b. Was the developmental assistance provided to the protégé useful to enhance its core capabilities? Given the specific developmental assistance provided to Protégé, describe the intern’s strengths as a potential professional.

Line 14c. How would you improve DOT’s Mentor-Protégé program? Describe how you would enhance DOT’s Mentor Protégé program.

Line 14d. What other factors, relevant to the developmental assistance, would you like to comment upon? Describe additional performance factors, if any, that the evaluator would like to comment upon.

Line 14e. Has the protégé been able to compete in federal procurement opportunities since the Mentor-Protégé agreement was signed? Describe whether the protégé has been able to compete on federal procurement opportunities.

Line 14f. Other Comments. Enter other general comments related to the Mentor Protégé program, if any.

Line 14g. Would the mentor or the protégé be willing to participate in the program again in the future? Check “Yes” or “No” to indicate the companies’ willingness to participate on the Mentor Protégé program in the future.

Line 15. Reviewer’s Signature. Sign and date the application. This section is for official use only.

OST F 5020.2 (2-12) Page 1 of 4 OPI:  Office of Small Disadvantaged Business Utilization