36C25818R0026-002.docx

PAST PERFORMANCE REFERENCES ATTACHMENT

REFERENCE #1

POC Name: _______________________________________________________________ Title: _____________________________________________________________________ Agency Address: ___________________________________________________________ Phone Number: ____________________________________________________________ Email address: _____________________________________________________________ Contract Title: ______________________________________________________________ Contract No: _______________________________________________________________ Contract POP: ______________________________________________________________ Contract Value: _____________________________________________________________ Relevant Work Description: ____________________________________________________

REFERENCE #2

POC Name: _______________________________________________________________ Title: _____________________________________________________________________ Agency Address: ___________________________________________________________ Phone Number: ____________________________________________________________ Email address: _____________________________________________________________ Contract Title: ______________________________________________________________ Contract No: _______________________________________________________________ Contract POP: ______________________________________________________________ Contract Value: _____________________________________________________________ Relevant Work Description: ____________________________________________________

REFERENCE #3

POC Name: _______________________________________________________________ Title: _____________________________________________________________________ Agency Address: ___________________________________________________________ Phone Number: ____________________________________________________________ Email address: _____________________________________________________________ Contract Title: ______________________________________________________________ Contract No: _______________________________________________________________ Contract POP: ______________________________________________________________ Contract Value: _____________________________________________________________ Relevant Work Description: ____________________________________________________

· Provide verified, up-to-date contact information.

PRESENT/PAST PERFORMANCE QUESTIONNAIRECONTRACTOR PERFORMANCE REPORT

Service(s) provided to you by the contractor: (please check all that apply)

· Information Engineering (Development & Data Management)

· External Application Integration

· Transition Planning

· Other (please specify in space below)

Has the Offeror worked for you in the last 3-year period?

· YES

· NO

Contractor performed as the _____ Prime, _______Sub-Contractor, _____ Key Personnel

Contractor Number: ___________________________________________________________________ Contract Value: ______________________________________________________________________ Contract Award Period: ____________________ to ______________________

Contractor Name: __________________________ Contractor Address: ________________________

Reference Name: ________________________________ Submitted for: ____________________

Reference Telephone #: ___________________________ Reference Activity: ________________________________

Description: __________________________________________________________________________

Ratings: Please summarize the contractor’s performance and circle in the column on the right the letter that corresponds to the performance rating for each rating category Assign each area a rating of E (Exceptional), A (Acceptable), or U (Unacceptable)

2. Were there sufficient internal quality control or review systems in place from the onset of the contract?

4. How would you rate your level of satisfaction with the effectiveness of their performance?

6. How would you rate the contractor’s ability to monitor quality, appropriateness of care, access, and patient satisfaction

7. How would you rate the contractor’s ability maintain up-to-date medical records in a computerized Record Tracking package