ATTACHMENT_H_Past_Performance_Questionnaire_Survey.docx

ATTACHMENT H –PAST PERFORMANCE QUESTIONNAIRE LETTER

Date:

Dear Client:

We are currently responding to the Health Resources and Services Administration (HRSA) Solicitation No. 13-250-SOL-00005 entitled, “HRSA Evaluation Studies IDIQ.” The Government is placing increased emphasis in its acquisition process 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:

ATTN: Diane Coger 13-250-SOL-00005 HRSA/Office of Acquisitions Management and Policy Parklawn Building 5600 Fishers Lane, Room 13A-55 Rockville, Maryland 20857 Phone: 3014432583 Email: dcoger@hrsa.gov

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 Contract Specialist at the above address or email, dcoger@hrsa.gov, no later than April 26, 2013 at 10:00 am or by email at dcoger@hrsa.gov.

We thank you for your prompt response in this matter.

Sincerely, (To be signed by Offeror)

PAST PERFORMANCE INFORMATION SURVEY QUESTIONNAIRE

FOR: ________________________________________________________________________

Name of Company

PLEASE RETURN COMPLETED SURVEY TO:

HRSA/OAMP/CAD – Attn: Diane Coger Parklawn Building 5600 Fishers Lane, Room 13A-55 Rockville, Maryland 20857 Email: dcoger@hrsa.gov 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

Approximate Percentage of Work Competed by Subcontractors: ______ % General Description or work 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.

Standard Contractor Performance Report

Additional or Alternate Contractor Name:

Requirement Description:

Ratings

Summarize contractor performance and check the number which corresponds to the rating for each rating category (See attached Rating Guidelines).

Quality of Product or Service _0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent _5=Outstanding

Government Comments for Quality of Product or Service (2000 characters maximum):

Cost Control (Rating and Comments for Cost Control are not required if contract type is Fixed-Price) _0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent _5=Outstanding

Government Comments for Cost Control (2000 characters maximum):

Timeliness of Performance _0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent _5=Outstanding

Government Comments for Timeliness of Performance (2000 characters maximum):

Business Relations _0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent _5=Outstanding

Government Comments for Business Relations (2000 characters maximum):

Additional Info

Subcontracts

Are subcontracts involved? __Yes __No (Check one) Comment on subcontracts (2000 characters maximum):

Contractor Key Personnel

Contractor Manager/Principal Investigator (name):

Comment on Contractor Manager/Principal Investigator (2000 characters maximum):

Contractor Key Person (name):

Comment on Contractor Key Person (2000 characters maximum):

Contractor Key Person (name):

Comment on Contractor Key Person (2000 characters maximum):

Customer Satisfaction

Is/was the contractor committed to customer satisfaction? _Yes _No (Check one)

Would you recommend the selection of this firm again? _Yes _No (Check one) –

Comments on Customer Satisfaction (2000 characters maximum):

Admin Info

Project Officer/COR Name:

Phone:

Fax:

E-mail Address:

Contracting Officer:

Name:

Phone:

Fax:

E-mail Address:

Rating Guidelines

Quality of Product or Service

0 = Unsatisfactory 1 = Poor 2 = Fair 3 = Good 4 = Excellent 5 = Outstanding

Cost Control

0 = Unsatisfactory 1 = Poor 2 = Fair 3 = Good 4 = Excellent 5 = Outstanding

Timeliness of Performance

Business Relations