ATTACHMENT_B.pdf

ATTACHMENT B

REFERENCE QUESTIONNAIRE PACKAGE

INFORMATION AND FORMS

Instructions to Offeror for sending Reference Questionnaire Forms:

Offeror: Prepare and send a reference questionnaire package for at least three relevant projects completed in the past ten years. It is your responsibility to follow-up and to encourage your references to send in their questionnaire. Your questionnaire package should contain the following.

Cover Letter (See attached SAMPLE) Past Performance Evaluation Questionnaire

Complete Part 1 (To Be Completed by Firm Requesting Reference) of each Questionnaire before sending it to the individual who will be providing the reference.

PLACE THE NAME OF THE ENTITY MAKING THE SUBMITTAL TO THE

IDIAN HEALTH SERVICE AND THE SOLICITATION NUMBER, 15-249-

SOL-00003 IN THE HEADER SO THEY APPEAR ON EACH QUESTIONNAIRE

PAGE

OFFEROR SHOULD DELETE THESE INSTRUCTIONS BEFORE SENDING OUT

QUESTIONNAIRES

SAMPLE TRANSMITTAL LETTER

Your Company Letterhead

Date: _________________ To: ______________________________________

We have listed you as a reference for work we have performed for your firm as noted on the attached questionnaire. Our firm intends to submit a proposal under a solicitation no. 15-249-SOL-00002 for the Tucson Area Indian Health Service (TAIHS). In accordance with the TAIHS’s Rules and Regulations, they will evaluate our firm's past performance. Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible.

Space is provided for comments.

Please send your completed questionnaire to the following address to arrive NOT LATER THAN Wednesday, December 03, 2014.

ADDRESS: Tucson Area Indian Health Service, 7900 South. J. Stock Road, Tucson AZ 85746 ATTENTION: Nadine Joe, Contract Specialist E-Mail: nadine.joe@ihs.gov FAX Number: 520/295-2626

Questionnaires may be mailed, faxed or e-mailed to the above address. E-Mail is preferred.

If you have questions regarding the attached questionnaire, or require assistance, please contact Nadine Joe, Contract Specialist for the Tucson Area Indian Health Service at 520/295-2464. Thank you for your assistance.

Signature and Title mailto:nadine.joe@ihs.gov

CDB Project Number: _________________

OFFEROR NAME________________

PAST PERFORMANCE EVALUATION QUESTIONNAIRE

Part 1 (To Be Completed by Firm Requesting Reference)

1. Name/Title, Firm Name & Address (City and State):

2. Title of Project/Contract Number:

3. Description of Project for Which Reference is Requested (Include type of work/trades performed):

4. Complexity of Work: High ________ Mid _________ Routine __________

5. Location of Work:______________________________________________

6. Role on Project: Prime Subcontractor/Subconsultant

7. Contract Amount:_______________________________

8. Date of Award: ________________________

9. Status: Percent complete __________ Project Completion Date: Scheduled Actual

Part 2 (To Be Completed by Person Providing Reference)

Reference is provided by: ____________________________ Company/Agency:_________________________________________________________________ Business Address;________________________________________________________________ Telephone Number: _______________________________________________________________ E-Mail Address: __________________________________________________________________ Relationship to Contract: ___________________________________________________________

If the information provided in Part 1 is not accurate, please indicate and correct.

Return completed questionnaire (pages 1-4) via email to nadine.joe@ihs.gov, or FAX (520/295-2626) or mail to: Tucson Area Indian Health Service-Attn: Nadine Joe, 7900 South J. Stock Road, Tucson,, AZ 85746 . Mark cover sheet of fax or subject line of e-mail or outside of envelope: Attention: SOLICITATION NO.15-249-SOL-00003 “Reference Questionnaire.”

1. QUALITY OF WORK/SERVICES:

Evaluate performance in complying with contract requirements, quality achieved and overall technical expertise demonstrated.

Excellent Quality Above Average Quality Average Quality Below Average Quality Unsuccessful or Experienced Significant Quality Problems Remarks: _____________________________________________________________

2. CUSTOMER SATISFACTION:

To what extent were the end users satisfied with: Quality? Cost? Schedule?

Exceptionally Satisfied Q____ C_____S____ Highly Satisfied Q____ C_____S____ Satisfied Q____ C_____S____ Somewhat Dissatisfied (please explain) Q____ C_____S____ Remarks:

3. TIMELINESS OF PERFORMANCE:

To what extent were contract performance requirements met? Consider also such things as;

contract performance period requirements; provided submittals in a timely manner; timely completion of punch-list items; timely submission of close out documents. Was timely and satisfactory response to warranty issues after project completion provided? How well managed were the firm’s availability and quality of clinical education phone support provided during the warranty period for specified training hours.

Completed Substantially Ahead of Schedule Completed on Schedule with no Time Delays Completed on Schedule with Minor Delays Under Extenuating Circumstances OTHER (explain)______________________________________________________ Remarks: _____________________________________________________________

4. COST CONTROL: DOCUMENTATION

Ability to complete contracts within budget (at or below); reasonableness of price change proposals submitted; providing current, accurate, and complete billings. To what extent were change submittals and other required documentation/billing accurate, complete?

Excellent Quality Above Average Quality Average Quality Below Average Quality Unsuccessful or Experienced Significant Quality Problems Remarks: _____________________________________________________________

5. BUSINESS RELATIONS: COORDINATION

Evaluate if the contractor provided effective management; ability to manage projects involving subcontracts if applicable; working relationship with the Contracting Officer and technical representatives; reasonable/cooperative behavior; flexibility; effective contractor recommended solutions; businesslike concern for Government's interests.

Excellent Above Average Average Below Average Unsuccessful Remarks: _____________________________________________________________

6. Did the company provide or offer training for use and management of equipment?

How many hours of training were provided for each?

BIOMED training for management of equipment

On-Site Technologist training for use of equipment

Were the courses helpful to both the technologist and the biomedical staff?

Yes No

Remarks:

If given the opportunity, would you work with this firm again?

Yes ___________ No ____________ Not Sure ____________ Remarks:

OTHER REMARKS:

Use the space below to provide other information related to the contractor's performance. This may include selection of subcontractors/subconsultants, flexibility in dealing with contract challenges, payment issues, their overall concern for the client's interest (if applicable), project awards received, etc.

ATTENTION: Nadine Joe, Contract Specialist