10. Past Performance Questionnaire.pdf

Past Performance Questionnaire

15BFA024R00000009

Updated: 08-03-2023 Page 1 of 4

REFERENCE IDENTIFICATION

Name of Reference

Address

Phone

E-Mail

Date Completed

CONTRACT IDENTIFICATION

Contractor Name for whom questionnaire is completed:

Contract Number:

Contract Type:

Period of Performance:

Estimated Value of Contract, including all options:

Description of Services:

Number of BOP locations serviced by this contract:

EVALUATION

Below are listed specific questions relating to the following six categories of contractor performance: quality of services, timeliness of deliverables/adherence to performance schedule, cost control, management, utilization of small business, and regulatory compliance. Please rate the contractor for each question based on the following guidelines. There is a comment section provided below each question.

RATING SCALE – CONTRACTOR’S PERFORMANCE

Please use the following ratings to answer the questions regarding a contractor’s performance. Please include an explanation to support the rating for each question.

RATING DEFINITION

(E) Exceptional Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective action taken by the contractor was highly effective.

(VG) Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with minor problems for which corrective actions taken by the contractor were effective.

(S) Satisfactory Performance meets contractual requirements. 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 element being assessed reflects a serious problem for which the contractor has not yet identified corrective action.

(U) Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the contractor‘s corrective actions appear or were ineffective.

(N/A) Not Applicable No information or did not apply to contract.

Updated: 08-03-2023 Page 2 of 4

RATING SCALE – USE OF SMALL BUSINESS

Please use the following ratings to answer the question regarding a contractor’s use of small business as subcontractors.

Please include an explanation to support the rating for each question.

SECTION 1 – QUALITY OF MEDICAL SERVICES

Quality of medical care provided to inmates was consistent with community standards.

Rating: _________________________ Brief Explanation of Rating Given:

SECTION 2 - TIMELINESS OF CONTRACT DELIVERABLES/ADHERENCE TO PERFORMANCE

SCHEDULE

Compliance with contract deliverables, i.e. appointments, requests for information, accurate invoices within 90 calendar days after an inmate’s discharge or outpatient encounter (or as specified in the contract) and/or written reports by the attending physician documenting the circumstances of the inpatient treatment, outpatient procedure, or other consultation provided to the COR within ten business days of the inpatient discharge, outpatient procedure, or other consultation (or as specified in the contract).

RATING DEFINITION

(E) Exceptional Exceeded all statutory goals. Had excellent success with initiatives to assist, promote, and utilize entities from the various socio-economic categories. Went above and beyond the required elements of the subcontracting plan and other small business requirements of the contract/order. Completed and submitted Individual Subcontract Reports and/or Summary

Subcontract Reports in an accurate and timely manner.

(VG) Very Good Met all statutory goals. Had significant success with initiatives to assist, promote, and utilize entities from the various socio-economic categories. Endeavored to go above and beyond the required elements of the subcontracting plan and other small business requirements of the contract/order. Completed and submitted Individual Subcontract

Reports and/or Summary Subcontract Reports in an accurate and timely manner.

(S) Satisfactory Demonstrated a good faith effort to meet all of the negotiated subcontracting goals in the various socio-economic categories. Full-filled the requirements of the subcontracting plan in the contract/order. Completed and submitted Individual Subcontract Reports and/or

Summary Subcontract Reports in an accurate and timely manner.

(M) Marginal Deficient in meeting key subcontracting plan elements. Did not submit Individual

Subcontract Reports and/or Summary Subcontract Reports in an accurate and timely manner. Failed to satisfy one or more requirements of a corrective action plan currently in place.

(U) Unsatisfactory Noncompliant with any small business participation requirement in the contract/order. Did not submit Individual Subcontract Reports and/or Summary Subcontract Reports in an accurate and timely manner. Showed little interest in bringing performance to a satisfactory level or is generally uncooperative.

(N/A) Not Applicable No information or did not apply to contract.

Updated: 08-03-2023 Page 3 of 4

SECTION 3 – COST CONTROL

Contractor cooperation with the Government in the review of invoices to ensure accuracy, the adjudication of medical claims, and efforts to control the cost out-of-network medical services.

SECTION 4 – MANAGEMENT

Effectiveness by the Contractor in managing a network of community-based medical providers, open communication with Contractor’s key personnel, answering questions as needed, and knowledge/expertise of

Contractor’s point of contact.

SECTION 5 – UTILIZATION OF SMALL BUSINESS

Achievements of Contractor with initiatives to assist, promote, and utilize small business, small disadvantaged business, woman-owned small business, HUBZone small business, veteran-owned small business, and service disabled veteran-owned small business.

SECTION 6 – REGULATORY COMPLIANCE

Contractor’s adherence to the terms and conditions of the contract.

SECTION 7 – RECOMMENDATION

Would you recommend this contractor for the award of additional contracts based on the contract services provided?

[ ] Yes [ ] No

Comment:___________________________________________________________

Updated: 08-03-2023 Page 4 of 4

SECTION 8 – ADDITIONAL COMMENTS