ATTACHMENT_A_PAST_PERFORMANCE_QUESTIONNAIRE_RFP_15-249-SOL-00039.doc

ATTACHMENT A

PAST PERFORMANCE-QUESTIONNAIRE PACKAGE

INFORMATION AND FORMS

Instructions to Offeror for sending Reference Questionnaire Forms:

Offeror: Prepare and send a questionnaire package for at least three relevant projects completed in the past two (2) 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. ALSO, PLEASE NOTE THE INDIAN HEALTH SERVICE AND THE SOLICITATION NUMBER, 15-249-SOL-00039 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: _________________ (Company Name)__________________________

Dear _____________, 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-00039 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 Friday, September 25, 2015.

ADDRESS:

Tucson Area Indian Health Service, 7900 South. J. Stock Road, Tucson AZ 85746

ATTENTION:

Katheryn Camacho, Contract Specialist E-Mail:

katheryn.camacho@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 Katheryn Camacho, Contract Specialist for the Tucson Area Indian Health Service at 520/295-2472. Thank you for your assistance.

Signature and Title

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: FORMCHECKBOX Prime FORMCHECKBOX Subcontractor/Subconsultant

7. Contract Amount:_______________________________

8. Date of Award: ________________________

9. Status: Percent complete __________

Project Completion Date: Scheduled FORMCHECKBOX Actual FORMCHECKBOX

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 1-3) via email to katheryn.camacho@ihs.gov, or FAX (520/295-2626) or mail to: Tucson Area Indian Health Service-Attn: Katheryn Camacho, 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-00039 “Past Performance Questionnaire.”

1. QUALITY OF WORK/SERVICES:

Evaluate performance in their ability to perform services specifically relevant to the subject Statement of Work

Remarks: _____________________________________________________________

2. CUSTOMER SATISFACTION: To what extend were you satisfied with the Contractor’s services.

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

3. TIMELINESS OF PERFORMANCE:

To what extent were contract performance requirements met by Providing current, accurate and complete reports, reliability, responsiveness to issues or concerns

4. COST CONTROL: DOCUMENTATION

Ability to complete contracts within budget (at or below).

5. BUSINESS RELATIONS: COORDINATION

Evaluate if the contractor provided effective management; working relationship with the contracting officer or other project manager; reasonable/cooperative behavior; flexibility; effective contractor recommended solutions; businesslike concern for firm’s interests.

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.