5Attachment 4 - Past Performance Survey.docx

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Hospital Assessment Consulting Services
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86615619R00018
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86615619R00018 Attachment 4

PAST PERFORMANCE SURVEY

This past performance survey is to be completed on the designated contractor or key personnel as designated below:

PAST PERFORMANCE PROJECT IDENTIFICATON (To be filled out by the Offeror):

CONTRACTOR OR KEY PERSONNEL NAME:
Click here to enter text.
CONTRACT or ORDER NUMBER:
Click here to enter text.
PROJECT TITLE:
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TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS
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PAST PERFORMANCE REFERENCE INFORMATION (To be filled out by the Reference):

NAME:
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TITLE:
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AGENCY or CUSTOMER:
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PHONE:
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E-MAIL
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The Department of Housing and Urban Development (HUD) is procuring the services described in the box below. You have been selected by the contractor or key personnel identified above to provide past performance information to HUD to be used in evaluating the offeror’s proposal for this acquisition. Thank you for your input.

Summarize the services acquired here.
If this past performance survey is related to key personnel, please summarize the level of interface you had with the designated key personnel throughout the life of the project you oversaw.

For each of the Five (5) criteria listed below, the rater must choose One (1) Adjectival Rating by checking the box, as applicable. At a minimum, for any rating that is checked Marginal or Unsatisfactory, please submit additional comments to substantiate the rating. If Cost Control is N/A, Please explain why.

1. QUALITY OF SERVICE

RATING
Adjectival Rating
Definition

Exceptional Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective

Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective

Satisfactory Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory

Marginal Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.

Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.

ADDITIONAL COMMENTS:

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2. SCHEDULE

RATING
Adjectival Rating
Definition

Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective

Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective

Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory

Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.

Click here to enter text.

3. COST CONTROL

RATING
Adjectival Rating
Definition

Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective

Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective

Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory

Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.

Not Applicable

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4. BUSINESS RELATIONS

RATING
Adjectival Rating
Definition

Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective

Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective

Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory

Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.

Click here to enter text.

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