Section_J_-_Attachment_H_-_Past_Performance_Questionnaire.docx

SECTION J ATTACHMENT H

PAST PERFORMANCE INFORMATION SURVEY QUESTIONNAIRE

Solicitation Number 14-250-SOL-00011

FOR: ________________________________________________________________________

(Name of Company you are completing this Past Performance Questionnaire for)

PLEASE RETURN COMPLETED SURVEY VIA EMAIL TO MFOREMAN@HRSA.GOV or to:

HRSA/OAMP/CAD– Attn: Marisha Foreman Parklawn Building, Room 13A-55 5600 Fishers Lane Rockville, Maryland 20857 Email: MForeman@hrsa.gov Fax: 301-480-1727

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 Personnel (name):

Comment on Contractor Key Person (2000 characters maximum):

Contractor Key Personnel (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

Outstanding The contractor has demonstrated an outstanding performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Excellent".

Business Relations