PAST PERFORMANCE INFORMATION for 11-250-SOL-00134.doc

PAST PERFORMANCE INFORMATION

SURVEY QUESTIONNAIRE

HRSA/OO/OAMP

FOR: _____________________________________

NAME OF COMPANY BEING EVALUATED

PLEASE RETURN COMPLETED SURVEY TO:

HRSA/OAMP – Attn: David Trejo – 11-250-SOL-00134

PARKLAWN BUILDING, ROOM 13A-19

5600 FISHERS LANE

ROCKVILLE, MARYLAND 20857

PHONE: 301‑443‑0534 FAX 301-443-5462

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 COMPETED 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 ‑1 ‑2

2. Accuracy of reports

+2 +1 ‑1

3. Effectiveness of personnel

‑1

4. Technical excellence

‑1 ‑2

COST CONTROL

1. Record of forecasting and controlling target costs +2 +1 ‑1 ‑2

2. Current. Accurate and complete billings

+2 +1 ‑1 ‑2

3. Relationship of negotiated costs to actuals

+2 +1 ‑1

4. Cost efficiencies

‑1 ‑2

TIMELINESS OF PERFORMANCE

1. Met interim milestones

‑1

2. Reliability

‑1

3. Responsive to technical direction

‑1 ‑2

4. Completed on time including wrap up and contract administration

‑1

5. Met delivery schedules

‑1

6. Liquidated damage assessed: yes/no

BUSINESS RELATIONS

1. Effective management, including subcontracts

+2 +1 ‑1

2. Reasonable/cooperative behavior

‑1

3. Responsive to contract requirements

‑1

4. Notification of problems

‑1

5. Flexibility

‑1

6. Pro‑active vs. Reactive

‑1 ‑2

7. Effective small/small disadvantaged business subcontracting program

‑1 ‑2

CUSTOMER SATISFACTION

1. The contractor is committed to customer satisfaction +2 +1 ‑1 ‑2

2. Would you recommend selection of this firm again?

+2 +1 ‑1 ‑2

GENERAL OVERALL RATING OF CONTRACTOR

+2 +1 0 ‑1 ‑2

ADDITIONAL COMMENTS: