Past Performance Questionnaire.docx

Hospitalist, Family Medicine and/or Internal Medicine Physician

PAST PERFORMANCE QUESTIONNAIRE

1. Contract Number: ____________________________________________

2. Indicate whether you were the prime contractor or subcontractor.

[ ] Prime Contractor [ ] Subcontractor

3. Contract Award Period:_________________________________________

4. Contract Type (e.g., Fixed-Price, Cost-Reimbursement, etc.)

5. Contract Term (e.g., One Year, Base Year and Options).

6. Contract Dollar Value:__________________________________________

7. Name of Procuring Organization:

8. Address of Procuring Organization:

9. Contracting Officer’s Name and Phone Number:

10. Program Manager or COTR’s Name and Phone Number:

11. Provide information on problems encountered on the identified contract and the corrective action taken.

12. Provide a brief summary of the work accomplished and how it relates to the work required by this solicitation.

45208-PO-21 Sources Sought Notice Page 1