Attachment C.docx

ATTACHMENTC

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration Office of Acquisition Management and Policy

5600 Fishers Lane Rockville, MD 20857-5600

Date

Dear Client:

We are currently responding to the Health Resources and Services Administration Solicitation No. 10-250-SOL-00084-ebd-1R entitled Family Health History Tool Community-based Dissemination and Integration in HRSA-funded Health Centers. The Government is placing increased emphasis in its acquisition on past performance as a source selection factor and is requiring that clients of firms responding to HRSA solicitations be identified and their participation in the evaluation process be requested.

Therefore, enclosed is a past performance questionnaire for your completion. We are requesting that you complete the questionnaire and send it directly to HRSA at the following address:

HHS/HRSA/OAMP/DCO

Attn: Elizabeth B. Downey 5600 Fishers Lane, Room 13A19 Rockville, MD 20857 Tel 3014430332 Fax 3014435462

Since this information will be used as one of the evaluation factors for contract award, we are requesting that you complete this questionnaire and return it to the HRSA at the above address no later than June 28, 2010.

We thank you for your prompt response in this matter.

Sincerely, (To be signed by offeror)

PAST PERFORMANCE INFORMATION - SURVEY QUESTIONNAIRE

FOR: [ OFFEROR'S COMPANY NAME_________________________________________]

PLEASE RETURN COMPLETED SURVEY ASAP but no later than June 28, 2010 to:

HHS/HRSA/OAMP/DCO

Attn: Elizabeth B. Downey 5600 Fishers Lane, Room 13A19 Rockville, MD 20857 Ref: 10-250-SOL-00084-ebd-1R Tel 3014430332 Fax 3014435462

PLEASE FILL IN THE FOLLOWING:

YOUR NAME:___________________________

YOUR AGENCY:_____________________________

ADDRESS:_______________________________________

PHONE NUMBER:___________________________

FAX :__________________________________

SIGNATURE OF PERSON COMPLETING SURVEY:______________________

CONTRACT NUMBER/SOLICITATION NUMBER: ____________________________

YOUR ROLE IN THIS CONTRACT CIRCLE ONE

PROJECT OFFICER CONTRACTING OFFICER CONTRACT SPECIALIST

CONTRACT VALUE (INCLUDING OPTIONS): $___________________________________________

PERIOD OF PERFORMANCE (INCLUDING OPTIONS):_____________________________________

TYPE CONTRACT (I.E. COST REIMBURSEMENT, FIXED PRICE, ETC.):__________________________

APPROXIMATE PERCENTAGE OF WORK COMPLETED BY SUBCONTRACTORS: _________ %

GENERAL DESCRIPTION OR TITLE OF CONTRACT: _____________________________________

RATINGS: Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Comments to support rating may be noted on last page.

NUMERICAL RATINGS ARE DEFINED AS FOLLOWS:

+2 EXCELLENT Based on the Offeror=s performance record, no doubt exists that the Offeror will successfully perform the required effort. A significant majority of sources of information are consistently firm instating that the Offeror=s performance was superior and that they would unhesitatingly do business with the Offeror again.

+1 GOOD Based on the Offeror=s performance record, little doubt exists that the Offeror will successfully perform the required effort. Most sources of information state that the Offeror=s performance was good, better that average, etc., that they would do business with the Offeror again.

0 None No past performance history identifiable.

1 MARGINAL Based on the Offeror=s performance record, some doubt exists that the Offeror will successfully perform the required effort. Many sources of information make unfavorable reports about the Offeror=s performance and express concern about doing business with the Offeror again.

2 POOR Based on the offeror=s performance record, serious doubt exists that the Offeror will successfully perform the required effort. A significant majority of sources of information consistently stated that the Offeror=s performance was entirely unsatisfactory and that they would not do business with the Offeror again.

PLEASE CIRCLE THE NUMERICAL SCORE INDICATING YOUR RATING

QUALITY OF SERVICE

1. Compliance with contract requirements +2 +1 0 1 2

COST CONTROL

TIMELINESS OF PERFORMANCE

4. Completed on time including wrap up and

BUSINESS RELATIONS

7. Effective small/small disadvantaged business subcontracting program +2 +1 0 1 2

CUSTOMER SATISFACTION

GENERAL OVERALL RATING OF CONTRACTOR +2 +1 0 1 2

ADDITIONAL COMMENTS: