Attachment_7-_Past_Performance_Questionnaire.docx

Attachment 4- Past Performance Questionnaire Past Performance Questionnaire Centers for Medicare & Medicaid Services

RFQ #160548

The Centers for Medicare & Medicaid Services (CMS) requests the completion of the Past Performance Questionnaire to assist CMS with the Past Performance evaluation for the solicitation. Please return the Past Performance Questionnaire to the attention of the individuals named below.

CMS

Contracting Officer Name: Rico Batte Phone: 410-786-7934 Email: Rico.Batte@cms.hhs.gov

Contracting Specialist Name: Kelli King Phone: 410-786-2046 Email: Kelli.King@cms.hhs.gov

Thank you in advance for your prompt response and assistance!

SECTION 1: CONTRACT IDENTIFICATION/to be Completed by the Contractor

A. Contractor: _________________________________________________________________

B. Contract number: ____________________________________________________________

C. Contract type: _______________________________________________________________

D. Was this a competitive contract? Yes _____ No _____

E. Period of performance: _______________________________________________________

F. Initial contract cost: $_________________________________________________________

G. Current/final contract cost: $___________________________________________________

H. Reasons for differences between initial contract cost and final contract costs:

I. Description of service provided:

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION/to be Completed by the Contractor

Customer or agency name, address, POC, and POC’s title:

SECTION 3: EVALUATOR IDENTIFICATION/to be Completed by the Person Responding to the Questionnaire

A. Evaluator’s name and title: ______________________________________________________________________________

B. Evaluator’s contact information: ______________________________________________________________________________

C. Number of years evaluator worked on subject contract:

SECTION 4: EVALUATION/to be Completed by the Person Responding to the Questionnaire

Please indicate your satisfaction with the contractor’s performance by placing an “X” in the appropriate block using the scale provided to the right of each question. This scale is defined as follows:

CODE PERFORMANCE LEVEL

E EXCELLENT - The contractor has demonstrated an outstanding performance level that was significantly in excess of anticipated achievements and is commendable.

G GOOD – The contractor met or in some instances exceeded the contract performance requirements.

A ACCEPTABLE – There were no, or very minimal issues during the contract performance and the contractor has met the contract requirements.

P POOR - The contractor required significant Government oversight in order to meet the contract requirements.

U UNACCEPTABLE – The contractor was unable to meet most of the contract requirements even with significant Government oversight.

N NOT APPLICABLE - Unable to provide a score.

Ability to understand/comply with contract objectives and technical requirements

Effectiveness of assigned personnel in terms of the appropriate mix of education and experience to accomplish the requirement

Adequacy/effectiveness of quality control program

Quality/effectiveness of sub-contracted efforts

Effectiveness of overall contract management (including ability to effectively lead, manage and control the program)

Timeliness/effectiveness of contract problem resolution without extensive customer guidance

Ability to successfully respond to emergency and/or surge situations

Effectiveness of material management (including Government Furnished Property or Material)

Contractor proposed alternative and innovative methods/processes that reduced costs and benefited the customer in other ways

Contractor implemented responsive/flexible processes to improve quality and timeliness of support

Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes)

Contractor ability to smoothly transition resources and personnel

Contractor effectiveness on maintaining continuity of mission support while transitioning/phasing in resources and personnel to support other efforts

Ability to hire/apply a qualified workforce to this effort

Ability to retain a qualified workforce on this effort

Accuracy in forecasting contract costs

Ability to meet forecasted costs and perform within contract costs

Ability to alert Government of unforeseen costs before they occur

Sufficiency and timeliness of cost reporting

Government Contracts Only: Has/was this contract been partially or completely terminated for default or convenience or are there any pending terminations?

If yes, please explain:

SECTION 5: NARRATIVE SUMMARY/to be Completed by the Person Responding to the Questionnaire

What were the contractor’s greatest strengths in the performance of the contract?

What were the contractor’s greatest weaknesses in the performance of the contract?

Please provide any additional comments concerning this contractor’s performance, as desired.

Signature: ________________ Date: ________________ Printed Name: _________________________

SOURCE SELECTION SENSITIVE IAW FAR 2.101 & FAR 3.104 (WHEN FILLED IN)