Exhibit_E.5__Past_Performance_Information_Spreadsheet.xlsx
XLSX spreadsheet 26 KB Posted
- Attached to
- Provider Enrollment and Oversight Federal contract opportunity
- Solicitation number
- 75FCMC18R0014
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Exhibit E.5
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Offeror Info
| Exhibit E. 5 | |||||||||||||||
| Prime Offeror Name: | Requirements Prime Offeror Proposing on (Place a "X" under each requirement) | Fingerprinting Services | Provider Enrollment Data Analysis Services | Provider Enrollment Systems Testing Services | Provider Enrollment Requirements Services | Adverse Legal Action Services | Provider Enrollment State Oversight Services | Provider Enrollment Accreditation Services | Enrollment Waiver for Moratoria Services | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Eastern | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Western | Provider Enrollment Education and Outreach Services | Competitive Bidding Implementation Contractor (CBIC) – License Verification Services | Site Verification Services - Eastern | Site Verification Services - Western |
| Significant Subcontractor's Name(s): Significant Subcontractor – A subcontractor performing major or critical aspects of the requirements relevant to the prospective contract. | Small/Large? If Small also provide socioeconomic type if applicable, i.e. WoSB, HubZone | Fingerprinting Services | Provider Enrollment Data Analysis Services | Provider Enrollment Systems Testing Services | Provider Enrollment Requirements Services | Adverse Legal Action Services | Provider Enrollment State Oversight Services | Provider Enrollment Accreditation Services | Enrollment Waiver for Moratoria Services | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Eastern | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Western | Provider Enrollment Education and Outreach Services | Competitive Bidding Implementation Contractor (CBIC) – License Verification Services | Site Verification Services - Eastern | Site Verification Services - Western | |
| Ex. ABC Company | Ex. Small, SDVoSB | Place a "X" under each respective requirement; ex. X | Percent of work being done by this significant subcontractor*, ex. 25% |
*Work defined as subcontractor labor hours relative to prime labor hours
Prime Past Performance Info
| Customer (Agency) | Federal, State, Local Government or Commercial | Contract Number | Program Title | Prime or Subcontractor | DUNS | Type of Contract | Contract Vehicle | POC Program Side Name, Phone and Email Address | POC Administration Office Name, Phone, Email Address | Total Contract Value | Period of Performance | Description of Services/Supplies | Type of Past Performance Documentation Submitted in Support | Additional Information | LARGE BUSINESS ONLY Subcontracting Plan Submitted? | Which Requirement(s) is this Relevant to? (of which the Offeror is proposing) | Fingerprinting Services | Provider Enrollment Data Analysis Services | Provider Enrollment Systems Testing Services | Provider Enrollment Requirements Services | Adverse Legal Action Services | Provider Enrollment State Oversight Services | Provider Enrollment Accreditation Services | Enrollment Waiver for Moratoria Services | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Eastern | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Western | Provider Enrollment Education and Outreach Services | Competitive Bidding Implementation Contractor (CBIC) – License Verification Services | Site Verification Services - Eastern | Site Verification Services - Western |
| Enter Customer or Agency Name | Designate who contract was with | Contract number or identifier | Enter the Program Title | Performed as the Prime Contractor or Subcontractor? | What DUNS this effort was performed under | Enter Type of Contract, i.e. CPFF, FFP | IDIQ, Task/Delivery Order, Stand-Alone, etc. | Point of Contact (Contracting Officer's Representative or other for Commercial Contract) and contact information | Point of Contact (Contracting Officer, Contract Specialist or other for Commercial Contract) | Approximate total contract value | Contract period of performance, by base and option year(s) | Description of contracted services/supplies | Enter the type of performance evaluation documentation submitted in support of this contract, i.e. PPIRS/CPARS, PPQ | If performance was documented as less than satisfactory, the Offeror shall provide a summary of the identified issues, steps taken to resolve the problem and processes in place to improve future performance. | IF A LARGE BUSINESS -Identify whether a subcontracting plan was required in compliance with FAR 52.219-8 and FAR 52.219-9. If one was required, please confirm that the eSRS report(s) for the contract is provided under Factor 5. | For each relevant requirement to the right -explain under the relevant requirement how the disclosed contract’s past performance information is relevant to the subject requirement |
Sig Sub 1 Past Performance Info
| Significant Subcontractor: | Enter Name | ||||||||||||||||||||||||||||
| Customer (Agency) | Federal, State, Local Government or Commercial | Contract Number | Program Title | Prime or Subcontractor | DUNS | Type of Contract | Contract Vehicle | POC Program Side Name, Phone and Email Address | POC Administration Office Name, Phone, Email Address | Total Contract Value | Period of Performance | Description of Services/Supplies | Type of Past Performance Documentation Submitted in Support | Additional Information | Which Requirement(s) is this Relevant to? (of which the Offeror is proposing) | Fingerprinting Services | Provider Enrollment Data Analysis Services | Provider Enrollment Systems Testing Services | Provider Enrollment Requirements Services | Adverse Legal Action Services | Provider Enrollment State Oversight Services | Provider Enrollment Accreditation Services | Enrollment Waiver for Moratoria Services | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Eastern | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Western | Provider Enrollment Education and Outreach Services | Competitive Bidding Implementation Contractor (CBIC) – License Verification Services | Site Verification Services - Eastern | Site Verification Services - Western |
| Enter Customer or Agency Name | Designate who contract was with | Contract number or identifier | Enter the Program Title | Performed as the Prime Contractor or Subcontractor? | What DUNS this effort was performed under | Enter Type of Contract, i.e. CPFF, FFP | IDIQ, Task/Delivery Order, Stand-Alone, etc. | Point of Contact (Contracting Officer's Representative or other for Commercial Contract) and contact information | Point of Contact (Contracting Officer, Contract Specialist or other for Commercial Contract) | Approximate total contract value | Contract period of performance, by base and option year(s) | Description of contracted services/supplies | Enter the type of performance evaluation documentation submitted in support of this contract, i.e. PPIRS/CPARS, PPQ | If performance was documented as less than satisfactory, the Offeror shall provide a summary of the identified issues, steps taken to resolve the problem and processes in place to improve future performance. | For each relevant requirement to the right -explain under the relevant requirement how the disclosed contract’s past performance information is relevant to the subject requirement |
Sig Sub 2 Past Performance Info
| Significant Subcontractor: | Enter Name | ||||||||||||||||||||||||||||
| Customer (Agency) | Federal, State, Local Government or Commercial | Contract Number | Program Title | Prime or Subcontractor | DUNS | Type of Contract | Contract Vehicle | POC Program Side Name, Phone and Email Address | POC Administration Office Name, Phone, Email Address | Total Contract Value | Period of Performance | Description of Services/Supplies | Type of Past Performance Documentation Submitted in Support | Additional Information | Which Requirement(s) is this Relevant to? (of which the Offeror is proposing) | Fingerprinting Services | Provider Enrollment Data Analysis Services | Provider Enrollment Systems Testing Services | Provider Enrollment Requirements Services | Adverse Legal Action Services | Provider Enrollment State Oversight Services | Provider Enrollment Accreditation Services | Enrollment Waiver for Moratoria Services | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Eastern | National Provider Enrollment Services (PART's A, B, C, DMEPOS and/or Medicaid) - Western | Provider Enrollment Education and Outreach Services | Competitive Bidding Implementation Contractor (CBIC) – License Verification Services | Site Verification Services - Eastern | Site Verification Services - Western |
| Enter Customer or Agency Name | Designate who contract was with | Contract number or identifier | Enter the Program Title | Performed as the Prime Contractor or Subcontractor? | What DUNS this effort was performed under | Enter Type of Contract, i.e. CPFF, FFP | IDIQ, Task/Delivery Order, Stand-Alone, etc. | Point of Contact (Contracting Officer's Representative or other for Commercial Contract) and contact information | Point of Contact (Contracting Officer, Contract Specialist or other for Commercial Contract) | Approximate total contract value | Contract period of performance, by base and option year(s) | Description of contracted services/supplies | Enter the type of performance evaluation documentation submitted in support of this contract, i.e. PPIRS/CPARS, PPQ | If performance was documented as less than satisfactory, the Offeror shall provide a summary of the identified issues, steps taken to resolve the problem and processes in place to improve future performance. | For each relevant requirement to the right -explain under the relevant requirement how the disclosed contract’s past performance information is relevant to the subject requirement |
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