2.2.1- ATTACHMENT 5 – Past Performance Questionnaire 70B06C26R00000017 A0001.docx

RFP 70B06C26R00000017- Attachment _5_

Past Performance Questionnaire

On behalf of:

Company’s (Quoter’s) Name:

POC, Title/Position:

Email Address:

Contract/Purchase Order No.:

Contract Awarded Amount:

Current Contract Dollar Value:

Period of Performance:

Location of Performance:

Business Address:

Phone Number:

Your candid responses are critical to the evaluation of the offeror’s capability and reliability for a contract award. You may be contacted for clarification.

Completed by:

Company’s Name:

POC, Title/Position:

Email Address

Business Address:

Phone Number:

Past Performance Survey: In connection with a pending solicitation, the Government must evaluate the above-listed contractor’s capability and capacity to successfully perform certain requirements. To assist this evaluation, please assess the contractor’s performance on your contract, task order or project using the following ratings in your assessment. Please include comments in the “Narrative” space provided to explain each rating given. You may be contacted to clarify comments and/or ratings:

Exceptional – Performance exceeded the contract requirements in most cases. No problems were encountered.

Very Good - Performance met, and in some cases exceeded the contract requirements. If there were any problems, they were minor in nature, which the contractor resolved in a timely, effective manner.

Satisfactory – Performance met the contract requirements. There were some minor problems which the contractor resolved in a timely, effective manner.

Marginal - Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective.

Unsatisfactory - Performance did not meet most of the contractual requirements. There were numerous problems of a serious nature, for which corrective action was ineffective.

Unknown - No record of past performance or the record is inconclusive.

1. Quality and Accuracy of Medical Services

a. Medical Examinations and Testing How would you rate the contractor’s ability to deliver accurate and complete medical examinations, fitness tests, and drug testing services in accordance with contract requirements and federal guidelines?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

b. Compliance with Standards and Regulations How well did the contractor comply with applicable federal, state, and agency regulations (e.g., HHS, SAMHSA, HIPAA, CBP Medical Standards, Drug-Free Workplace Program requirements)?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

2. Timeliness and Schedule Adherence

a. Timely Completion of Services How would you rate the contractor’s ability to meet required timelines for scheduling, conducting, and reporting results of medical exams, fitness tests, and drug testing?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

b. Responsiveness to Urgent or Special Requests How would you rate the contractor’s responsiveness to urgent, expedited, or out-of-schedule requests (e.g., post-accident testing, reasonable suspicion testing, or remote/overseas services)?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

3. Security and Confidentiality

a. Protection of Sensitive Information How would you rate the contractor’s performance in safeguarding personally identifiable information (PII), sensitive health information, and compliance with privacy/security requirements?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

4. Communication and Reporting

a. Communication with Government Representatives How would you rate the contractor’s communication with your agency regarding scheduling, status updates, incident reporting, and issue escalation?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

b. Accuracy and Timeliness of Reports and Invoices How would you rate the contractor’s accuracy and timeliness in submitting required reports, documentation, and invoices?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

5. Contract Administration and Management

a. Adherence to Contract Terms How would you rate the contractor’s adherence to all contract terms, including deliverables, staffing, and quality control requirements?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

b. Management of Subcontractors and Facilities If applicable, how would you rate the contractor’s management of subcontractors, medical facilities, and collection sites?

Rating: ☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory ☐ Unknown Comments:

[Insert comments]

6. Overall Performance Please provide any additional comments on the contractor’s strengths, weaknesses, or notable performance related to the delivery of medical support services, compliance, or contract administration.

[Insert comments]

7. Recommendation Given what you know today about the contractor’s ability to fulfill their contractual obligations, would you choose to work with them again?

☐ Definitely Would ☐ Probably Would ☐ Probably Would Not ☐ Definitely Would Not