Attachment 6_DMAT_Past Performance Questionnaire.docx

Disaster Medical Assistance Team (DMAT) Medical Staffing and Support Page 1 of 2 Solicitation Number: 75A50224R00003

Disaster Medical Assistance Team (DMAT) Medical Staffing and Support Page 1 of 2 Solicitation Number: 75A50224R00003

ATTACHMENT 6

PAST PERFORMANCE QUESTIONNAIRE SURVEY

This survey pertains to (VENDOR NAME): ______________________

Department/Component: _____________________________________

Contract Number: ______________________

Date of Survey: ___________________

Name of Person Completing Survey: ______________________________

Signature of Person Completing Survey: ________________________________

Your Company/Agency: __________________________

Your Role in this Contract (circle one):

Contracting Officer Contract Specialist Project Officer Other ________________________

Contract Value (including options): $__________________________

Performance Period: __________________________________ (Including option periods)

Type of Contract: __________________________________

Approximate percentage of work being performed (or completed) by subcontractor(s): _________%

Information on subcontractor(s) (where more than ____% of work was completed by the subcontractor):

General description of products/services required under the contract: _______________________________________

RATINGS

Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Commentary to support rating may be noted at the end of the questionnaire under ‘additional comments. Assign each area a rating of 0 (Unsatisfactory), 1 (Poor), 2 (Fair), 3 (Good), 4 (Excellent) or 5 (Outstanding). Use the attached Rating Guidelines as guidance in making these evaluations. Circle the appropriate rating. If you do not have enough personal knowledge or feedback from internal customers who directly received products and services from the Contractor to make a determination on any of the performance criteria below, please circle “N/A” (not applicable /no opinion).

QUALITY OF SERVICE

4. Technical excellence 0 1 2 3 4 5 N/A

COST CONTROL

4. Cost efficiencies 0 1 2 3 4 5 N/A

TIMELINESS OF PERFORMANCE

4. Completed on time including wrap-up and contract administration 0 1 2 3 4 5 N/A

6. Liquidated damages assessed: Yes No (circle one)

BUSINESS RELATIONS

4. Notification of problems 0 1 2 3 4 5 N/A

CUSTOMER SATISFACTION

ADDITIONAL COMMENTS

RATING GUIDELINES

5 – Outstanding: The Contractor has demonstrated an outstanding performance level in any of the above four categories that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances when Contractor performance clearly exceeds the performance levels described as “Excellent”.