B09_SA_-_Amendment_1_-_Attachment_D_-_Past_Performance_Questionnaire_0001.docx

ATTACHMENT D: Department of Health and Human Services (HHS), Indian Health Service (IHS), Health Information Technology (IT) Modernization Program for the Four Directions Warehouse (4DW) ISBEE Set-Aside – Past Performance Questionnaire

SECTION A (TO BE COMPLETED BY OFFEROR)

CONTRACT INFORMATION:

A. Contractor: _________________________

B. Contractor Address: ___________________________

C. Contract/Task Order Number: __________________ Status: Active _____ Completed _____

D. Performed as Prime Contractor or Subcontractor: ________________

E. Project Title: _______________________________________________

F. Contract Type: ______________________________________________

G. Original Contract Value: $___________________

H. Final (or current, if still active) Total Contract Value: $________________

I. Number of FTEs provided by entity listed in item A: ________________

J. Planned Period of Performance: _______________________

K. Actual Period of Performance: __________________________

L. Project Description (Include discussion on size, scope, and complexity. In addition, include how this project is relevant to the scope of work listed in the PWS and how lessons learned will be applied):

SECTION A (CONTINUED)

M. Contracting Officer Name, Agency/Organization, and Contact Information (if applicable):

N. Customer or End User, Agency Contracting Officer’s Representative, Task Monitor, or Program Manager Name and Contact Information (Phone Number and Email):

O. Name of Reference, Organization, and Contact Information (Phone Number and Email):

SECTION B (TO BE COMPLETED BY REFERENCE)

***Add Additional Lines to Each Response as Needed***

1. Is the contract accurately described above? If not, please provide additional clarification.

2. Describe the contractor’s labor force in terms of overall qualifications to perform the work required. Please provide as much detail as possible.

3. Describe the stability of the contractor’s work force as affected by employee turnover and contract vacancies. Please provide as much detail as possible.

4. Describe the contractor’s willingness and ability to integrate as a team and work cooperatively with the existing work force (Government and/or other contractors). Please provide as much detail as possible.

5. Describe the contractor’s effectiveness in forecasting, managing, and controlling contractor order cost.

SECTION B CONTINUED

6. Describe the contractor’s commitment to your satisfaction as a customer and concern for your business interests. Please provide as much detail as possible.

7. Describe the contractor’s overall performance. Please provide as much detail as possible.

8. Would you be willing to have this contractor do additional work for your Organization in the future?

9. Is there anything else worth noting regarding the contractor’s performance on this project not already addressed in one of the questions above?

SUBMIT COMPLETED PAST PERFORMANCE QUESTIONNAIRE NO LATER THAN TBD TO:

Rachael Zack, Contracting Officer Email: Rachael.zack@ibc.doi.gov

Important Note: Completed questionnaire shall be submitted to the Contracting Officer by the reference and NOT by the contractor being evaluated. Completed questionnaires received from the contractor will not be accepted.