Attachment_3_-_Past_Performance_Questionnaire.docx

Attachment 3 – Past Performance Questionnaire for RFP 13-100-SOL-00016

PAST PERFORMANCE CONTACT INFORMATION SHEET

AND QUESTIONNAIRE (RFP 13-100-SOL-00016)

PART I – Past Performance Contact Information [to be completed by Vendor] Instructions: The Vendor shall complete Part I of this Attachment for each past performance reference. The Vendor shall forward this form (with a completed Part I) to each of its references for completion, with instructions to forward the completed questionnaire to the Contracting Officer (NOT BACK TO THE VENDOR) before the time set for receipt of quotations. The completed questionnaires should be forwarded by email directly from the Vendor’s reference to Brendan Miller at Brendan.Miller@hhs.gov. Please include “RFP 13-100-SOL-00016” in the subject line of any submissions. >.

Vendor Information:

Name of Vendor Providing Services: ____________________________________________

Address: ____________________________________________________________________

Past Performance Reference Information:

Name of Agency/Organization Receiving Services: _________________________________________________________

Address: _____________________________________________________________________

Telephone: _________________________ FAX: _____________________________

Contract Information:

Contract Number: _____________________ Dollar Value (Annual): _______________

Performance Period: ___________________ Performance Location: _______________

Type of Contract (Check all that apply):

Fixed Price ______ Cost Reimbursement ______ Other (specify) _________________

Negotiated ______ Sealed Bid ______ Competitive ______ Non-Competitive _______

Basis of Payment:

Labor/Equipment Hours _______ Other (specify) _____________

Type & Extent of Subcontracting: ________________________________________________

Description of Services Provided: ________________________________________________

Briefly Describe How this Work Correlates with HHS's Current Requirements: ________

Part II: Past Performance Questionnaire Contact [to be completed by Agency or Organization Receiving Services]

Instructions: The following questionnaire will be considered in a Federal Communications Commission competitive acquisition being conducted among GSA multiple award schedule holders. The Vendor who provided this questionnaire to you wishes to have your responses considered as part of the HHS’s past performance evaluation in the acquisition. Please complete the questionnaire and provide an electronic copy of it to Brendan Miller at Brendan.Miller@hhs.gov by Tuesday, July 9th, 2013. Please include “RFP 13-100-SOL-00016” in the subject line of any submissions..

Answers to Questions 1-3 are for general information and are needed to place the remaining questionnaire answers in context. For questions 4- 15 please provide a narrative response and a rating. Detailed narrative responses serve as the most important guide to future performance. Therefore, HHS regards your narrative responses as the most important aspect of this questionnaire and would deeply appreciate your time in preparing those responses. Please also rate the Vendor on a scale of 1-10, where one (1) represents a completely unsatisfactory experience and ten (10) an outstanding experience, with the Vendor with respect to the subject of the question. We would especially appreciate narrative elaboration for ratings that are very low (1-3) or very high (8-10). If you have no experience with the Vendor on the identified contract with respect to the question, select N/A.

1. Please identify the individual completing this questionnaire.

Name:

Title:

Present Employer:

Telephone Number:

E-Mail Address:

2. What was your relationship to, and role with respect to, the contract identified in Part I above?

3. Is the contract accurately described?

4. What were you experiences with the quality of the services provided by this Contractor?

Bold or Underline a Rating: 1 2 3 4 5 6 7 8 9 10 N/A

5. What were your experiences with the Contractor’s adherence to contract schedules?

6. What were you experiences with the Contractor’s overall ability to meet schedules for delivery of reports.

7. What were you experiences with the Contractor’s ability to meet any special requirements for expedited delivery or service?

8. What were your experiences with the Contractor’s conforming to contract requirements generally?

9. What were your experiences with the Contractor’s standards of professionalism?

10. What were your experiences with the Contractor’s controlling costs and working with you to limit additional costs and, if you are a Government agency, to limit upward equitable adjustments to the Government’s price in the event of changes?

11. What were your experiences with the Contractor’s integrity and business ethics?

12. What were your experiences with the Contractor’s spirit of cooperation and fairness of business dealing with you?

13. What were your experiences with the Contractor’s commitment to your satisfaction as a customer and concern for your business interests?

14. What were your experiences with the Contractor’s reporting into Government databases to which it was obliged to report?