2.2.1 Attachment 8 - Past Performance Questionnaire - v2 101322.docx

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Attached to
REQUEST FOR PROPOSAL: FEMA Medical and Behavioral Health Services
Solicitation number
70FA4023R00000001
Issued by

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2.2.1 SOLICITATION 70FA4023R00000001 - SF1449 (v4 - 102122).pdf PDF
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1.1.3 PWS Medical and Behavioral Health Services - v2 Corrected 101322.pdf PDF
2.2.1 Attachment 2 - Pricing Template (v2 - corrected) 101322.xlsx XLSX spreadsheet
2.2.1 SOLICITATION 70FA4023R00000001 - SF1449 (v3 - 101322).pdf PDF
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2.2.1 Attachment 4 - FAR 52.204-26 (Contains Fill-ins).pdf PDF
2.2.1 SOLICITATION 70FA4023R00000001 - Schedule thru Section M.pdf PDF
2.2.1 Attachment 3 - FAR 52.204-24 (Contains Fill-ins).pdf PDF
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(Offeror to complete Part I prior to providing this questionnaire to the Evaluator.)

In order to assess potential vendors under the above-referenced solicitation, 70FA4023R00000001the DHS/FEMA Contracting Office is obtaining past performance information with respect to each offeror. The contract resulting from this procurement will provide DHS/FEMA with support for Medical and Behavioral Health Services in support of FEMA’s fixed and disaster sites through the US and its territories. In addition to this questionnaire, you may receive a follow-up phone call to confirm or clarify information. This is a critical acquisition being conducted by DHS/FEMA and your support is sincerely appreciated. We are thanking you in advance for your time, effort, and cooperation in responding to this questionnaire.

CLIENT/EVALUATION SHALL RETURN THIS QUESTIONNAIRE VIA EMAIL TO DIRECTLY TO THE FOLLOWING CONTRACTNG OFFICERS sharon.edwards3@fema.dhs.gov and janice.joseph@fema.dhs.gov

<insert your company name above>

If you need more space than provided, attach additional pages. Responses will be treated as source selection sensitive information. If you have any questions, please contact the Contracting Officers at the e-mail address indicated above.

PART

I

TO

BE

COMPLETED

BY

OFFEROR

AND

TRANSMITTED

TO

CLIENT FOR COMPLETION.

A. CONTRACT INFORMATION:

NAME OF

CONTRACTOR/OFFEROR:

1
Agency Name/Location:
2
Program/Project Title:
3
Type of Instrument (e.g.

Contract/Order/Subcontract/Other):

4
Contract Identification Number:
5
Order Number (If applicable):

Attachment

Past

Performance

Questionnaire Solicitation:

70F A402 R000000

DHS/FEMA

Page of

6
Project Service Description (Add attachment if necessary):
7
Type of Contract (e.g.

Negotiated, Sealed Bid):

8
Pricing Type (e.g. fixed price,

cost reimbursement, other):

9
Competitive (Y/N):
10
Follow-on Work Available

(Y/N):

Follow-on Work Awarded to Offeror (Y/N):

11
Date of Award:
12
Initial Contract Dollar Value

(w/Options):

13
Final Contract Dollar Value

(w/Options):

14
Period of Performance:
15
Place(s) of Performance:
15
Complexity of Work (e.g.

difficult, routine, simple):

16
Type and extent of subcontracting (add rows if needed):

Past

Performance

Questionnaire Solicitation:

70FA402

R000000

DHS/FEMA

Page of

PART

II

TO

BE

COMPLETED

BY

OFFEROR’S

CLIENT

AND

E-MAILED

TO CONTRACTING OFFICER

S

A. REFERENCE RESPONDENT INFORMATION

1
Name (please print):
2
Agency / Company:
3
Position Title:
4
Phone Number (include area

code):

5
Fax Number (include area code):
6
Email Address:
7
Mailing Address:
8
Your Role Relative to the Project/ Contract (e.g., COTR, PM):
9
Length of Involvement in Project/Contract:
10
Questionnaire Completion Date:

Past

Performance

Questionnaire Solicitation: 70FA4023R00000001

DHS/FEMA

Page of

B. PERFORMANCE ASSESSMENT

Please rate the contractor’s performance on the identified program using the following rating scale. Assessments should reflect only contract performance for which the contractor is responsible.

Rating
Symbol
Definition

Outstanding

O Based on the Offeror’s record of past performance, no issues, concerns, or risks are associated with receiving timely services and contract performance. Past performance surveys and the Offeror’s experiences indicate that the Offeror is capable of significantly exceeding the requirements of the RFP.

Good

G The Offeror’s record of past performance indicates there is very little risk associated with receiving quality products, timely services and full contract performance. Past performance surveys and the Offeror’s experience indicate the Offeror is capable of exceeding the requirements of the RFP.

Acceptable

A The Offer’s record of past performance indicates that there is some potential risk associated with receiving quality products, timely services, and contract performance. Past performance surveys and the Offeror’s experience indicate the Offeror is capable of meeting the requirements of the RFP.

Unsatisfactory
U
The Offeror’s record of past performance indicates it is likely to

have problems meeting the requirements of the RFP.

Neutral

N No past performance/experience available for evaluation. Offeror has asserted that it has no directly related or relevant past performance experience. Proposal receives no merit or demerit for this factor.

C. PAST PERFORMANCE

Rating Scale:

O - Outstanding G - Good A - Acceptable U - Unsatisfactory N – Neutral.

Place an “X” in the box for the appropriate rating.

Quality
O
G
A
U
N
1
Overall quality of the project
2
Qualifications and quality of key personnel to meet

the objectives of the project

3
Procedures that ensured the level of quality

remained constant throughout the life of the project.

4
Adequacy, relevance and reasonableness of the

quality management approach, procedures, documentation and methods

5
Quality of products, materials and services for the

price paid

6
Accuracy of the record keeping procedure and ability to prepare accurate and timely reports
7
Ability to implement effective corrective actions

and improvements

Comments:

Cost Control
O
G
A
U
N
8
Demonstrated a process for management of the program costs and segmentation of costs for

improved manageability

9
Demonstrated financial stability during the project

performance period

10
Demonstrated effectiveness in reducing project

costs from the baseline cost estimates

11
Demonstrated reasonableness of proposed

modification costs

12
Demonstrated reasonableness in labor and O&M

costs

Timeliness
O
G
A
U
N
13
Timeliness in completing the overall project.
14
Completion of tasks in accordance with project

schedule’s critical milestone dates

15
Timeliness in completing reports
16
Timeliness of responses to client requests and

inquiries

Rating Scale:

O - Outstanding G - Good A - Acceptable U - Unsatisfactory N – Neutral Place an “X” in the box for the appropriate rating.

Business Relations
O
G
A
U
N
17
Demonstrated a business-like concern for your

agency’s / company’s interests

18
Relationship with client technical and functional

personnel

19
Relationship with contracting office personnel
20
Relationship with subcontractors
21
Cooperation and innovation in problem solving
22
Compliance with the terms of the contract
Management
O
G
A
U
N
23
Utilized effective program and project management

processes, tools, and reporting

24
Had satisfactory and complete management plan
25
Demonstrated effectiveness in use of risk

management to proactively reduce project disruptions

26
Ability to retain key personnel
27
Availability and accessibility of key personnel
28
Flexible in responding to changing needs
29
Adequate processes and metrics for the evaluation of their own overall management performance
30
Adequate subcontractor management procedures
31
Demonstrated effectiveness in risk identification,

escalation, response and monitoring procedures

32
Demonstrated effectiveness in capturing incidents

and resolving problems

33
Ability to provide a product or service that met

your mission requirements

Based on this Contractor’s overall performance, would you award them another contract? Why or why not? Did the provided solution from this contractor work and how well did it work?

D. ADDITIONAL REMARKS

Thank you for your assistance in supporting this source selection activity.

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