60RRBH20R0010 CMOS Past Performance Questionnaire (PPQ) Attachment 9.docx

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Consultative Medical Opinion Services (CMOS)
Solicitation number
60RRBH20R0010
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60RRBH20R0010 Page 2 of 3 Attachment 9 Consultative Medical Opinion Services

Past Performance Questionnaire

Contractor: __________________________________________________ Referencing Organization: ____________________________________ Name of Reference’s Contact: __________________________________________ E-Mail & Ph. # of Contact: ___________________________________ Dates of referenced Service(s):_______________________________

1. The RRB is considering this contractor to provide Consultative Medical Opinion Services and Other Professional Medical services as follows:

· RRB seeks the services of a group of licensed physicians (ref: Section III.D.) who shall provide services for the Disability Benefits Division (DBD). Required services are detailed in the following sections and include: (1) providing medical expertise, advice and consultation in the area of disability benefit and claim matters, (2) preparing advisory medical opinions for all bureaus and officesof the RRB and (3) providing training to the disability staff as required.

Please provide a paragraph synopsizing this contractor’s overall past performance in their contract engagement with you:

Please mark an “X” next to the applicable response below, and provide any comments specific to the below past performance sections, as appropriate.

2. Direct applicability of the referenced project:

Did this contractor perform this specific type of services for your organization?

A. Positively yes, the referenced project was virtually identical to what we are pursuing.___
B. Basically yes; the referenced project was generally similar to what we are pursuing.___
C. The referenced project was only slightly related to what we are pursuing.___
D. The project was fundamentally different than what we are pursuing.___

Comments: _____________________________________________________________________

3.Overall customer satisfaction:
How satisfied overall were you and others with the service provided?
A. Very satisfied with every aspect of the service.___
B. Relatively satisfied.___
C. Neither satisfied nor dissatisfied.___
D. Dissatisfied___

Comments: _____________________________________________________________________

Which of the following statement is most true considering all aspects of the project?

A. There were no contractor-caused problems of any kind. ___ B. Contractor-caused problems encountered were minor in nature and were remediated in a timely fashion. ___ C. Contractor-caused problems were significant but the contractor was willing to adequately remediate the problems. ___ D. Contractor-caused problems were significant and the contractor was unwilling to adequately remediate the problems. ___

Comments: _____________________________________________________________________

Taking the entire project into account, would you use this contractor again?

A. Yes, definitely.___
B. Yes, but with certain reservations.___
C. Maybe/maybe not.___
D. Never.___

Comments: _____________________________________________________________________

4. Quality of service:

What was the quality of the work performed?

A. Of the highest quality that could be expected.___
B. Exceeded minimum requirements.___
C. Met minimum requirements.___
D. Below minimum requirements.___

Comments: _____________________________________________________________________

To what extend did the contractor display initiative in meeting requirements?

A. The contractor displayed considerable initiative.___
B. The contractor displayed some initiative.___
C. The contractor displayed little initiative.___
D. The contractor displayed no initiative.___

Comments: _____________________________________________________________________

5. Reliability and timeliness of performance:

Was the contractor reliable and timely in their performance of your work?

A. Yes, in every situation.___
B. Yes, in most situations.___
C. To a minimum acceptable level.___
D. At an unacceptable level.___

Comments: _____________________________________________________________________

6. Business relations:

Did the vendor cooperate with your organization on business and contract administration issues?

A. Yes, in every situation.___
B. Yes, in most situations.___
C. To a minimum acceptable level.___
D. At an unacceptable level.___

Comments: _____________________________________________________________________

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